Toward effective service to individuals and low-nurturance families


Useful Clinical Intervention Techniques -
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By Peter K. Gerlach, MSW

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Continued -

  Distraction Check 

Goals - to (a) identify whether any client participant is significantly distracted from focusing on the work (i.e. whether they have significant physical discomfort and/or are controlled by a false self), and (b) to raise clients' awareness of their inner state and the importance of acknowledging and reducing any distractions (needs) when sustained concentration is required. 

Participants - one or more clients, in person or on the phone.

Preparations - the clinician should scan for and attend any significant personal distractions (needs) first. Options - (a) it may be useful to have discussed...

  • inner and outer awareness and personality subselves, to provide context;

  • the mutual value of the client not trying to please the clinician by pretending to be focused when they're significantly distracted (denial), and the clinician has... 

  • framed "distractions" - including all emotions - as useful signals that one or more subselves and/or their body needs the client's attention now;

  • that any planned session focus must be secondary to respecting and reducing current distractions ("first things first"); and...

  • that the clinician and clinical process are reliable and safe enough for the client, and s/he can stop the process if and when s/he needs to without shame or guilt. 

Best time to do this - at the start of any client session or strategic conversation.

Technique - ask "Are you aware of any physical, mental, or emotional distraction now that might defocus you from what we're about to do together?" Option - if prior interactions have revealed a frequent notable distraction, ask about it specifically ("On a scale of 1 to 10, how is your chronic pain / anxiety / inner uproar now?").

        If the client says something like "No, I'm fine," don't assume that's true. Option - ask "Who do you feel is guiding your (subselves) now?" This requires that the client understands the common inner and behavioral symptoms of true Self and false self control of their "inner family" of subselves.

        If the client reports one or more distractions, separate and rank them, and work to respectfully define one at a time( a) what the distraction is (e.g. "I feel kinda tight in my stomach."), and (b) what the client's body and/or ruling subselves need right now. ("OK, good. If the tightness could speak, what would it say it needs now?"; and/or "Ask the subself who's trying to communicate via your stomach muscles to give you thoughts, images, or senses of what s/he needs now.

        Option - if you are significantly distracted, consider describing this to the client/s and modeling what you need to do to attend your own needs before working together.

        Expect that if you are consistent at opening each contact with the clients this way, they'll anticipate your question and volunteer self-awareness - or better, note and reduce any distractions -  before you start working together.

Next - If there are no major distractions now, (a) remain comfortably alert for any that may occur in you and/or the client/s during the session, and (b) attend (respect) any that occur, unless you and the client agree they can be deferred for the time being. Options - ask the client to describe (a) how often s/he asks herself and/or other people about current distractions that might defocus himj or her from important conversations or negotiations, and/or (b) whether s/he feels any minor kids are learning to do the same.

   Test the Client's Imaging Ability 

        I warmly thank master life-coach Jeanne McLennan, RN, for this useful technique.

      Perspective: kids and adults vary in their ability to imagine (picture) real and imaginary things. Some people "sense" such things with little or no imagery, and others are able to automatically create and describe vivid inner (usually color) "pictures." The latter ability is needed for effective guided-imagery interventions. Perhaps all kids and adults have the innate ability to form inner images, and those that have trouble with this are unaware of being ruled by a false self that feels inner images are dangerous and/or worthless, and inhibits them.  

Goals - to have the client assess whether s/he is "visual" or not - i.e. is able to "focus inside" and experience clear inner images, including "picturing" (a) past and current events, people, and situations, and (b) things that aren't real.

Participants - an adult or child client, and the clinician, alone or in  a family session.

Best time to do this - when the clinician needs to assess the clients' ability to benefit from strategic guided-imagery interventions, and (b) both people are undistracted and guided by their true Selves.

Preparations - the clinician needs to (a) be comfortable with intrapsychic and inner-family work, (b) value  guided-imagery interventions in promoting desired systemic second-order changes, and (c) be skilled at providing strategic guided imagery.

Technique - seed awareness by ask something like "Do you know someone - past or present - who is good at forming vivid inner images or pictures?"  The client will usually say "Yes." Reassure the client that kids and adults vary in their ability to image, which is not related to being "healthy or "normal."

        Then ask "Do consider yourself a 'visual' person who can form clear inner images?" Regardless of the clients answer, ask "For instance, can you image your favorite cartoon figure / your Mother's childhood face / your own face in the mirror / your best friend / your (child's face) / last night's dreams now?" Expect answers to range between "Yes," to "sort of," to "No" without judgment. Note that some people can remember real things and situations, but can't picture abstract or fantasy images - or vice versa. Often clients have never thought about this imaging ability, and underrate their own. This is a small part of becoming self-aware.

        Option - ask if the client experiences day dreams, fantasies, and night dreams - and if so, if s/he forms images during those normal activities. 

Next - Use the observed outcome of this technique to (a) choose if, how, and when to offer guided-imagery interventions like the Future Self exercise (below) during the work, and to (b) decide if, how, and when to identify a protective subself who distrusts the resident true Self and blocks the client from imaging. Option - add this to the client's definition of her or his personal identity - "So among your unique qualities, you are (not) a 'visual' person."

  "Future Self" Experience 

        I'm grateful to Nancy Napier for this concept, which she describes in her 1990 book "Recreating Your Self"

Goals - to experientially motivate the client to expand his or her awareness, and refocus from local problems and immediate gratification to long-term options and desirable outcomes. The client may be confronted by a difficult choice now (e.g. whether or not to marry, have a(nother) child, move, change jobs, or end or shift a key relationship, or may feel unclear about their life direction and purpose now. 

Participants - one adult client and the clinician, alone or with other family members. Doing this in a group can help all participants become aware of their long-term outcomes and certain death.

Preparations - read this lay article, and  decide if the concept seems credible and viable to you. Your way of presenting this exercise to the client may be more effective if you meet with your own Future Self first. A helpful outcome is most likely if the client (a) is adept at inner imagery and inner dialogs, (b) acknowledges that at times s/he is guided by her or his resident true Self, and (c) has some experience at working to build cooperation among his or her subselves. The latter two are helpful but not required.  Clinical experience at and comfort with non-directive (Ericksonian) trance-induction techniques is useful also.

Best time to do this - when (a) you have at least 20" or more, (b) you and the client are locally undistracted and guided by your true Selves, and (c) you believe the client is able to visualize well and is open to guided imagery.

Technique - ask the client's opinion on where s/he has been focusing most, recently - the past, the present, or the future. Propose that s/he may make wiser choices in the present if s/he clarifies how s/he wants to feel as she approaches old age and death. 

        Ask him or her something like "How old do you expect to be when you die?" I've often been surprised by a wounded client's dominant subself replying "Before I reach (middle age)." Moral - don't assume the client expects to live a full life and die of old age as I used to do.

        As you ask about their death, watch for one or more protective (frightened) subselves blending with (disabling) the client's true Self. If that happens, consider...

  • using parts work to have the client's true Self identify, validate, and confidently reassure those subselves before continuing; or...

  • deferring this experience until the client is guided by her or his true Self.

        Describing or doing this Future Self exercise may lead to a productive exploration of the meaning and purpose of the client's life, personal spirituality, and accepting and using the inevitability of death to motivate breaking denials and living purposely in the present moment. This is unlikely if the client is often ruled by a false self.

        Option promote an experiential reference by asking the client to enjoy vividly recalling one or more gratifying experiences with wise older people, like a senior mentor, or trusted grandparen.

        Reassure the client that this is a safe, interesting exercise, and suggest that s/he may or will enjoy some helpful new awarenesses from it. Ask the client to get physically comfortable, close his or her eyes if s/he wishes, and start by focusing on her breathing. Use your preferred indirect trance-induction (inner focusing) technique, and ask the client to imagine her Future Self in bed in a peaceful surrounding, soon before her or his death.

        Suggest pulling up a chair to the bed, greeting this wise, serene, aged person, and introducing the client's younger (present age) self. Option - if appropriate, invite the client to ask her or his Higher Power to be present at this meeting - imaged or not - and to pray for guidance, peace, healing, and direction. Suggest that the Future Self is at peace with her approaching death, and needs to use the remaining time to pass on important learnings to his or her younger self.

        Remind the client that their Future Self already knows the outcome of key life-choices the client has yet to make, and wants to counsel her or him about those choices. Suggest the client trust her/his own wisdom to know what general or specific questions to ask, and be silent as s/he does this. If appropriate, after a time, ask the client to describe what's happening. let the client pace the experience, and allow as much time as it takes for some kind of closure to occur.

        Test this by asking quietly something like "Is there more you want to learn from your Future Self now? Know that you can always talk further with him/her again..." Watch the client's face and body language for clues as to how to proceed. If at any time you sense distress or loss of focus, ask "Do you wish to continue? What do you need right now?" Trust your and the client's true Selves to know the right thing to do at all times, use the Serenity Prayer, and let go of expectations about what "ought to" happen.

        When you sense the client has reached a stopping point, invite him/her to thank their Future Self and say goodbye for now. Option - invite the client to ask Future Self if it would be all right to talk again, and to be open to any response. Reorient the client by asking her/him to wiggle toes, arms, hands, shoulders, and head, and breathe well several times as s/he opens her eyes and looks around the room and at you. Invite the client to "take all the time you need" to reorient and consolidate this experience, without talking.

        If you sense the client is willing to - or needs to - vent about or process the experience, ask open-ended questions like "What was that like for you?" or "What are you aware of now?" Let the client lead. If you sense that talking would distract from the experience, close the session. Options - (a) summarize the purpose of the experience, (b) invite the client to journal about what s/he learned, and/or (c) talk about it in another session. Note your own reactions during and after the client's Future Self interview too - a chance for self-awareness!

Next - use strategic guided imagery with visual clients as appropriate.

  Creating "Triggers" (Strategic Associations)

        In this context, a trigger is a reflexive mental association between some object, sensory event, or action, and a desired thought or image.

Goal - to empower the client to remember something that they otherwise might "forget."

Participants - one client adult or child alone or in a group, and the clinician.

Preparations - you may explain what a trigger is and demonstrate one, or just do the exercise. Option - identify and use your client's reflexive mode of sensory reference (tactile, visual, audible, kinesthetic, or smell) to guide your choice of trigger.

Best time to do this - when you want the client to remember to try a new attitude or behavior outside the session (e.g. at home or work), alone or with other people. This technique can be specially helpful for clients doing inner-family work ("Use this trigger to remind you to check who is guiding your team of subselves in important situations") and practicing new communication skills ("Use this to remind you to notice  your R-messages and E-levels in important or conflictual situations.").

Technique - start by getting the client's agreement that they want to remember to do something outside the session. They may have already tried this and "failed" - e.g. "I get nervous and forget to practice good eye contact with my brother when he gets angry."

        Reassure the client this is a safe, useful reflex that they already know how to do. Reality-check this by asking her or him to describe present triggers - e.g. "When you see the picture of a turkey or a pumpkin, smell gardenias or wood smoke, or hear a baby cry, what images and thoughts comes to your mind? How did you learn to do this?"

        If the client hasn't identified his or her personality subselves yet, (a) verbally redefine the thing they want to remember, and (b) suggest several triggers they could use to remind them of it. Option - first ask if s/he thinks a bodily trigger would work best, a stimulus outside their body, or both (a double trigger). Examples of the first: "poking your tongue against your cheek or teeth," "Wiggling your toes inside your shoe," "rubbing your thumb and forefinger together," "clearing your throat," "touching part of your body," etc. The advantage of bodily triggers is that the client has access to them in all situations.

        If the client prefers an external trigger, choose common objects or chronic behaviors or attributes of another person to illustrate possibilities - e.g. "when you grasp a doorknob / hear your cell phone / hold  a fork / flip a (specific) light switch / smell his/her aroma / enter a room / brush your teeth / hear him laugh / say or think her or his name / picture (a target person) / see or hear your (pet) / see or touch your ring / start to dress / go to the bathroom /..." etc. Using general examples frees the client to choose his or her own specific associations.

        If the client has identified and validated his or her subselves, you have extra options. For example, you can suggest that a protective Saboteur or other well-meaning Guardian subself doesn't feel it's safe for you to remember (whatever), and blocks your doing that "for your own good." This opens up options for reassuring such a subself, and asking it to trust the true Self's ability to keep (the client) safe enough.

        Effective triggers may already be associated with some emotional, mental and/or physiological response - e.g. "When she calls you (something); or interrupts you; or says "yes but..."; or won't look at you; or gets loud, impatient, or critical; or "gets a certain facial expression; or ... (etc.)" You can use an existing response to trigger another one - e.g. "When you feel a surge of frustration with Norman, it can remind you to get clear on what you need and feel, and to use a respectful I-message with him."

       Once they decide on a trigger and the response they want it to remind them of, have the client describe the latter clearly and rehearse it several times. If the client is "visual" (adept at imaging), have them picture using this trigger in a selected location or situation. It's important that the client chooses the trigger, not the clinician.

Next - Tell the clients/he can create triggers for just about anything s/he needs to remember. Option - after rehearsing the trigger several times, ask the client something like "Do you expect this will work for you?" Or say "How do you feel your success with this new trigger will help you?" If the client is skeptical or pessimistic, suspect a well-meaning Guardian subself like the Cynic and/or Worrier is in control.

        As with all these techniques, follow up in a future conversation with the client - e.g. "Did you try your trigger, and did it work for you?" Some situations may require several iterations of focus and practice to have the trigger "take root."

  Reframing

        Most (all?) kids and adults automatically form mental/emotional/bodily responses to a wide range of sensory experiences, depending on their life experience so far. For example, what thoughts and feelings occur if you picture or see a large snake or spider, or a naked young adult? These responses are called "associations" below.

Goals - use this technique to reduce or eliminate a client's stressful chronic mental association with some personal trait, past or present event, and/or thought pattern - i.e. to induce a permanent shift in attitude or belief. "Stressful" means the existing association triggers  significant guilt, shame, anxiety, confusion, anger, blame, and/or dissociation (i.e. one or more subselves taking over the client's true Self), and related thought patterns.

        Example - if the client is divorced and thinks or encounters words like "divorce," "split up," or "broken home," her Inner Critic and Shamed and/or Guilty Child subselves may immediately activate and cause thoughts about personal "failure" and remorse over hurting his or her children.

        Alternatively, on hearing, thinking, or reading "trigger" words like these, subselves may activate a cycle of intense resentment, disgust, and rage and related thoughts focused on the client's former partner, parent, or someone else for "causing" divorce-related losses and pain. This reflex can significantly hinder (a) grieving progress and/or (b) cooperative co-parenting in divorcing families and stepfamilies.

Participants - one or more young or adult clients and the clinician, alone or in a group. The reframe may be designed for the client person, or one or several of their subselves in doing inner-family work.

Preparation - The clinician needs to genuinely believe in the reframe, or it may come across as phony or artificial. New clinicians often need to consciously decide to reframe. With practice, the technique  becomes automatic. An underlying requisite is that the clinician needs to believe s/he can c/overtly cause the client to use the innate human ability to perceive something from two (or more) points of view.

        It may simplify the work if the client understands and accepts the concept of working with individual personality subselves, but this is not a requisite. It can also help to have previously taught the client to distinguish shame from guilt, and how to reduce unwarranted major guilts over some perceived personal "failure," limitation, or "negative" trait.

Best time to use - when the clinician feels the client's stressful mental association with something is significantly slowing or blocking the work.

Technique - Five ways to use this powerful technique are...

  • directly ("I suspect it would help if you choose to see 'divorce' in a new way."); or indirectly - e.g. by suggestion ("Some people come to see 'divorce' as an important learning opportunity, rather than a failure.") or telling a real story or strategic fable;

  • didactically (teach the client what reframing is, why it's helpful, and how to do it); and/or experientially (no explanation);

  • vaguely (e.g. "Some people find major relief by shifting some key attitudes about certain things"), or specifically ("Your well-intentioned Inner Critic is abusing your inner children by constantly judging and blaming you for their pain");

  • working internally with specific subselves or not; and...

  • with several or all members of a client family - i.e. reframe several peoples' common stressful association with something.

        Situations where this technique can be effective are beyond generalizing. Some common themes with typical divorcing-family and stepfamily clients and trauma recoverers are:

  • reframing human needs and neediness from indicating weakness and childishness to normal, healthy emotional, physical, spiritual, and mental discomforts.

  • reframing problems, conflicts, issues, fights, arguing, and frustrations from being negative or bad to helpful signs of normal unmet needs.

  • reframing clashing needs, opinions, and/or values from being right or wrong, and good or bad to different and equally valid. 

  • reframing normal emotions like anger, guilt, shame, regret, anxiety, confusion, and sadness from being positive or negative to each and all emotions being natural, useful symptom of one or more needs to be filled.  

  • reframing an obnoxious, floundering, selfish, or inept child or adult from being "bad, sick, no good, or weak" to "wounded, unaware, unhappy, and helpless."

  • reframing an addiction (toxic compulsion) from being a weakness, illness, disease, or sickness to "an unconscious attempt to reduce relentless, intolerable inner pain - i.e. to self-medicate."

  • reframing denial and/or procrastination from being a weakness, character defect, bad habit, and/or cowardly to "protective subselves distrusting the Self to keep the host person safe from perceived danger, loss, or injury." 

  • reframing a marital affair from "a moral failing, betrayal, sin, and a disgusting, selfish, insensitive, irresponsible, shameful choice," to "a result of of unwise courtship choices, and/or (b) the mates never learning how to do effective win-win problem-solving together."

  • reframing the pejorative term abuse to the less provocative aggression, unless three conditions are clearly present. When they are, an option is to reframe the abuser as "dominated by a false self, and not knowing that or what to do about it," rather than being evil, bad, criminal, or perverted.

  • reframing dishonesty ("lying") from being "a despicable weakness, choice, and character flaw (or equivalent) " to "being in a relationship where it feels too unsafe to tell the truth, and not knowing how to fix that."

  • reframing "marital problems" from being the other partner's fault to the couple's wounds and inability to (a) identify their mutual relationship needs and fill them using effective communication skills."

  • reframing a hostile stepchild from selfish, arrogant, and ungrateful, to "an overwhelmed, wounded, shame-based girl/boy who hasn't been taught to grieve major losses and adapt to major changes yet." 

  • reframing stepfamilies from second best, abnormal, unnatural, and inferior to a common, normal type of family with the same potential to provide high nurturance (fill members' needs) as any other type of family.

  • reframing stepchildren from damaged, disadvantaged, inferior, and/or abnormal persons to young people facing a complex mix of normal development and alien family-adjustment needs which often their wounded, unaware adults can't help them fill effectively.

        Choosing what, when, and how to reframe depends on the clinician's style, beliefs, and experience, and the client's needs, personality, and situation. Notice that the theme of all the examples above is to shift stressful blame of self or another person toward compassion, empathy, and realistic optimism.

        To be consistently effective at this technique (have the client make stable second-order attitude shifts), it may be necessary to do inner-family work - i.e. to persuade the well-meaning Inner Critic, Perfectionist,   Bigot, and related Inner Children to trust the Regular subselves' reliable skill at keeping them all safe enough in most or all situations.

Next - after reframing, watch to see if the client demonstrates s/he is trying out the new view, in and outside clinical sessions. Option - ask if s/he is doing so, and - if so - what that feels like. If the reframe is successful at reducing stress, clients often report something like "That feels better." Option - repeat (reinforce) the reframe in the flow of the work ("Sounds like your partner / parent / coworker / friend is burdened by a false self, rather than insensitive and selfish.")

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Updated September 25, 2014