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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  Strategic Imagery 

        "Guided imagery" is the sophisticated art of intentionally using key words, sounds, and vocal dynamics to induce a desired response in a person or group. The power and utility of using guided imagery and c/overt suggestions in many situations has justified books, classes, and the arts of public speaking, advertising, medicine, religion, clinical and self hypnosis, and Neurolinguistics.

        Average kids and adults are often unaware of the scope and degree of the effects of their own responses to inner and external images, with and without other sensory stimuli like sounds and odors. This section offers brief perspective on using guided imagery in clinical work. Using imagery to help people recover from psychological wounds is described seperately.

Goals - use this technique to induce a desired situational or chronic response in a client or group.

Participants - the clinician and a child or adult client or a family group.

Best time to do this - when the clinician...

  • believes (a) a non-didactic experience is appropriate to the work (e.g. to get past a "resistance" or shift an inhibiting attitude or reflex), and that (b) the client/s have "enough" visual ability and (c) are currently undistracted and receptive; and the clinician...

  • instinctively or intentionally chooses a direct or indirect application of this technique.

Preparations - Results depend on the clinician's...

  • ability to (a) conceive a desired clinical outcome and (b) a viable strategy for using imagery to promote that outcome; and...

  • (c) knowledge of and (d) experience with proactively providing guided imagery with a range of people and circumstances, and the clinician's...

  • abilities to (e) attain and (f) maintain focused objective environmental (me - you - us) awareness.

        Clinicians need to be undistracted, self-aware, guided by their true Self, and able to manage any unexpected client responses - i.e. provide a safe experience. S/He may or may not ask the client's permission ("Are you open to doing some safe guided imagery work now?") and describe the technique and its purpose first. Ideally, the clinician will video the experience (with the client's permission) for later study alone or with a supervisor or peers.

Technique - three broad phases to this technique are: (a) mutual trance induction (optional), (b) an intentional sequence of words, sounds, and vocal dynamics from the clinician, who monitors and adjusts to the client's observed responses in real time to a natural stopping point, and (c) processing the experience if and as appropriate. 

 Mutual Trance Induction

        A trance ("going inside") is a momentary or sustained period of heightened focus on personal thoughts, images, "senses," and bodily sensations; and reduced awareness of external stimuli except for immediate danger. Trance states vary between slight to moderate to deep. People differ in their (a) natural and learned ability to experience full (vs. intellectual or pseudo) trances, and their (b) self-perception of this ability ("I'm no good at going into trances.") Typical survivors of childhood trauma are significantly adept at - or guarded against - sustaining moderate to deep trance states, depending on which subselves govern their personality in clinical situations. Many feel that fantasizing, imagining, day dreaming, "musing," and the transitions into and leaving REM sleep states are natural trance states.

        Clinical hypnosis paradigms offer various direct ("Your eyelids are becoming pleasantly heavy now...") and indirect ("You can be interested to learn how deep a trance you'll decide to relax into now...") ways to induce a trance state in a person or group. Methods usually include variations in...

  • physical relaxation, comfort, and sense of local security,

  • focusing on thoughts and breathing, and...

  • the clinician's instinctively or intentionally pacing his/her words and speech dynamics to the client's dynamic changes in breathing depth and rate, muscular relaxation or tension, eye closure and movement, minute movements, etc.

Trance inductions can be a word, phrase or sentence, and/or a conditioned body action like a gesture and/or sigh, or a longer sequence of clinician behaviors.

       Whether induction success depends on the clinician going into their own trance with the client or not is debatable. My experience is this is often natural and useful in maintaining special focus on the dynamic real-time zones of me + you + us.

       Note the option of using client "resistance" to establishing and maintaining a significant trance and/or inner imagery as a useful assessment and treatment-plan variable ("Seems like you have a well-intentioned subself who feels imaging and trances are too dangerous for now. Would you like to explore and change that safely?")

 Provide Strategic Guided Imagery

        Strategic implies that he clinician has (a) assessed the client system and (b) formed clear treatment goals, (c) drafted a treatment plan (strategy) to reach the goals, and (d) has decided that a planned or spontaneous guided-imagery experience is timely and appropriate in this phase of the strategy. Premise - a safe, vivid internal experience - with or without inner images - is just as powerful as an actual physical experience at causing, changing, or inspiring client awarenesses, motivations, and behaviors. How do you feel about this?

        A key variable is whether the clinician (a) tries to elicit a specific response in the client ("I want your Shamed Child to feel better about herself."), or (b) trusts the client's Manager subselves to choose the best response to a guided-imagery experience. I've experienced the latter as most effective for all involved, in most situations.

        Guided means that the clinician takes control of the dynamic process with the client, and offers a brief or sustained verbal/nonverbal sequence of behaviors to direct the client's inner experience toward some desired general ("Become more comfortable and effective in identifying and asserting your needs") or specific ("Learn to effectively confront your ex spouse on your child-support needs and consequences.") outcomes.

        Imagery means verbally descriptive, evocative words, phrases, sequences, and paraverbal dynamics  from the clinician that cause or invite general or specific images and associations in the client/s.

        The content and nature of useful guided images are beyond generalizing. One way to choose appropriate situational imagery is to ask in the context of specific clinical goals: "What imaginary (inner) experience can improve the client/s' confidence to try real interactions (like confrontations, or new esponses) with other family members or subselves?" In this context, guided imagery can preview or complement client-clinician role plays as rehearsals and learning experiences for new behaviors. 

 Process the Experience

        Three ways to "process" (reflect on, discuss, and learn from) guided-imagery interventions are (a) the client alone, (b) the clinician alone and/or with colleagues, and (c) the clinician and client together. Process focus options include examining the imagery experience in the context of ...

  • the client's presenting problems, and/or...

  • the clinician's treatment plan; and/or...

  • the apparent systemic results of the experience, and/or...

  • the technique itself- i.e. processing if, how, and when the client can learn to (a) do his/her own imagery work, and/or (b) model and teach it to other adults and kids.

Next - Follow up over time to see if the imagery had any significant effect on the client's attitudes, values, and behaviors. If not, asses s alone or with a co-worker whether (a) the image was ineffective or misguided, and/or (b) the client's protective false self is preventing the intended benefits of the imagery.

  Reduce Excessive Guilts

        Guilt is the automatic healthy neural/emotional/hormonal response to believing you have broken or violated someone's perceived or actual good/bad behavioral "rule" - i.e. a should (not), must (not), ought to, have to, or can not (e.g. "People shouldn't say "fart" or pass gas in public"). Guilts ("I did a bad thing") feel like - and promote - shame ("I am a bad thing"). These stressors are caused and reduced differently. Unwarranted guilt occurs when a child or adult is unaware of feeling badly for breaking someone else's rule which the person doesn't genuinely endorse.

        Moderate guilts are helpful behavior guides and regulators. Excessive local and chronic guilts cripple personal wholistic health, self-esteem, relationships, and family nurturance levels. Members of typical divorcing families and stepfamilies have many causes for excessive and unwarranted guilts - specially if one or more adults are unrecovering Grown Wounded Children (GWCs).

Goals - to teach the client/s to...

  • differentiate shame and guilt, and excessive and normal guilts;

  • see moderate guilts and shame as normal and helpful; and to...

  • show the client/s how to (a) validate guilts, and (b) reduce or let go of excessive and unwarranted guilts; and...

  • motivate client parents to (a) prevent excessive guilts in their dependent kids; and (b) teach their kids to notice, validate, moderate, and use their guilts effectively. 

Participants - the clinician and one or more adult and/or adolescent clients in any kind of family.

Best time to do this - when (a) a client complains of significant excessive or chronic guilt in themselves or in another person they care about, (b) other problems are not more pressing, and (c) you have at least 30" or so for the technique. Ideally, you and the client will also have covered basic assertiveness steps and techniques like respectful "I" messages.

Preparations - read these articles about psychological (false self) wounds and reducing excessive guilts for perspective. Options - also scan or read (a) this article on excessive shame and (b) this sample Bill of personal Rights. Consider having the client read and discuss one or more of these as part of your intervention.

Technique - lay some foundations first, and then demonstrate and use them with current excessive or chronic guilts.

  Foundation Options

        Ask if the client would be interested in learning an effective way to reduce their guilts to normal healthy levels. Option - if the client is a parent, ask if they would like to learn a practical way of teaching their child/ren how to effectively manage and use normal guilty feelings and thoughts.

         Ask the client to describe (a) their definition of "guilt," and whether they think it is usually a helpful response ("good") or stressful ("bad"). Then ask "When you feel significantly guilty, what do you usually do with it?" To make this concrete, ask for an example, and validate it with empathic listening (a "hearing check") - "So when your parent gets that look on her face, you feel guilty like you did as a child.").

         Describe and illustrate the concept of behavioral "rules" (should (not)s, have to's, must (not)s, can nots, ought to's, etc. Ask the client to describe several favorite rules s/he was taught as a child, or rules s/he is teaching her/his own kids. Option - describe several rules you were taught as a child. See if the client agrees that behavioral rules are required to maintain order and security in typical homes and families. Confirm that the client adopted the unconscious rule "I must obey and please my parents and other family adults", or equivalent. See if that rule also included  something like "...and I should never question or (openly) disagree with my parent's rules." Stay focused on the present.

        Ask if the client agrees that (a) guilty thoughts and feelings range from mild to crippling, and that (b) guilt feels similar to shame, but is different. Option - if appropriate, suggest that you'll discuss some practical options for reducing chronic or excessive shame ("low self esteem") at another time.        

        Propose that all emotions - including guilt - are useful signals that the person needs to do something. Implication: feeling guilty is potentially useful, not "bad." Option - use any guilts the client described to illustrate this ("So your old guilt reaction to your parent's 'look' is telling you to act in some way to fill a need.") Framing guilt as useful is usually new and intriguing to typical clients.

        Ask the client to validate that guilt feelings usually have associated thought patterns, which may amplify and/or prolong the feelings. A common example is this increasing guilt by thinking something like "I shouldn't feel so guilty about this." Option - ask "Who's rule is that - your own, or someone else's?"

        Suggest that all child caregivers dictate hundreds of behavioral rules to young children, who (a) can't evaluate the validity of them or (b) assert and enforce their own rules. "Growing up" involves reality-testing these original rules in various situations, and deciding whether to keep them or evolve more fitting rules. Thus any "broken" rule can be judged to be "someone else's" or "my own." For example, most independent adults unconsciously forge and act on their own rule like "I may or may not agree and comply with my parent's rules now. Either way, I'm OK - even if my parent/s disapprove."

        Illustrate outdated rules by telling a (true) story: A grown woman had unconsciously adopted her mother's rule that you had to cut a turkey in half before cooking it. When the woman's daughter asked why that was necessary, she said "Well, my Mom always did - I've never thought about why." The Mom asked her Mother why, and learned it was a custom dating from the time that her Mother's grandmother's oven was too small to hold a whole turkey, so she had to cut and cook it in halves.

        Validate this by asking if the client can identify someone else's rule that causes current (misplaced) guilt. If s/he can, ask how it would feel to think something like "That is ____'s rule, not mine. I don't have to feel badly for breaking other people's rules that I don't agree with."  Option - have the client say that forcefully to you, with steady eye contact, and notice how that feels.

        Verbally summarize these "guilt basics," or provide a printed summary:

  • Premise: all emotions - including guilt - are normal and useful indicators of unfilled needs.

  • In healthy kids and adults, guilty thoughts and feelings occur when the person believes they have broken one or more behavioral "rules" - shoulds, musts, ought to's, have to's, etc.

  • Guilt feels like - and promotes - shame, but is caused and managed differently.

  • Guilty feelings usually occur with related thoughts, which may prolong and/or amplify guilt.

  • "Growing up" includes validating or updating parents' childhood rules about "correct," "proper," or "good" behavior and attitudes. The implicit "meta-rule" (rule about rules) is "As a unique, worthy adult, I have the right to decide whether to obey other people's behavioral standards and rules, or to define and use my own rules to guide my decisions and actions."

  • I can learn to let go of unmerited guilts by (a) defining what specific rules I feel I've broken, and (b) deciding whose rule is it - my own or someone else's. If the latter, I claim the right to decide on my own moral and behavioral rules - without guilt or shame!

  • I can reduce excessive guilts by (a) identifying what needs my guilt is trying to alert me to, and (b) acting to fill the needs to reduce my legitimate guilts to normal levels. A common example is owning our behavior, and sincerely apologizing to someone we've hurt.

        Discuss any of these until (a) the client is comfortable with all of them, or (b) you conclude that his or her ruling subselves are not able to adopt these ideas now without ambivalence or undue anxiety. The latter suggests inviting the client to do some personal parts work if they have hit true bottom, or else plant seeds for that, and let go of responsibility for "fixing" the client.

  Use the Foundations

        Ask the client to identify three or four things that cause him or her significant guilt, and to pick one s/he wants to end or "reduce to normal." Use empathic listening to check the accuracy of your hearing, without judgment. Then ask the client to identify the specific rule or rules that s/he feels she is breaking. For each identified rule, ask "Who's rule is that - yours, or someone else's?"

        For each rule that the client feels is authentic (their own), then ask "What primary need/s are your guilty feelings and thoughts asking you to fill?" Options:

  • If appropriate, explain and illustrate the difference between surface and primary needs, and why distinguishing between them is useful in important, conflictual, and stressful situations;

  • Review the concepts of personal dignity (self respect), integrity, and rights, and ask if the client feels s/he has the undeniable right to fill his or her primary needs as a dignified, unique person. If the client is ruled by a false self, expect ambivalence, intellectualizing, and/or pretense;

  • Ask the client to say out loud her/his personal right to authenticate major behavioral rules - i.e. to differentiate personal rules from other people's rules); and...

  • Brainstorm and rank-order viable options for filling the client's relevant primary needs now.

  • Explore any barriers to acting on the best option, and practical options for reducing (problem-solving) them.

        For each rule the client feels is someone else's value, ask "Is anything in the way of forming and acting on your own rule to replace this one?" Two possible responses are (a) internal (inner-family) blocks, and (b) external blocks - e.g. "If I c/overtly reject my parent's rule, s/he'll cut me off / collapse / badmouth me to others / rage and scorn me / take it out on my kids / etc." Options -

  • Encourage the client to define a new personal rule to replace the old (other person's) rule, without imposing your own values. Invite her or him to experience their true Self saying the new rule out loud to you, with good eye contact. Use empathic listening to validate what you hear and perceive.

  • Explore whether it's useful and practical for the client to inform the rule-originator of adopting the new rule/s, and (b) why s/he's choosing to do that now ("Dad, I choose to give up my traditional guilt at not pleasing or agreeing with you now, and I need you to affirm my adult right to do that respectfully.")

  • Role play responding with respectful empathic listening and reassertion to old rule-owner's expected reactions like anger, hurt, misunderstanding, blame, ridicule, threats, or withdrawal. Watch for chances to identify and reduce habitual communication blocks.

        Next - Follow up to see whether the client tried to reduce their excessive guilts, and if so, what happened. If not, explore what blocks them (usually a protective false self). Reinforce the foundations and options above as appropriate, and affirm any successes. With successes (as viewed by the client), note the implication "You can change your basic beliefs and behaviors, if and when you need to.":

Strategic Helplessness

        I'm grateful to my Gestalt therapy instructor Dr. Ray Robertson, who suggested that "There are two kinds of useful therapy - supportive and frustrating." This technique is a version of the latter.

        This technique paradoxically implies that the clinician is responsible for helping the client solve their problems, and does so by strategically "not helping." Veteran clinicians who rely on the traditional medical model of "mental illness" and therapy - e.g. many psychiatrists - automatically assume full responsible for solve their individual clients' problems. Including "helping by not helping" in their paradigm may be a second-order (core attitude) change similar to replacing psychoanalytic therapy with family-systems principles. Related techniques are paradoxical interventions, like prescribing major symptoms. (You probably should get even more depressed.")

Goals - to respectfully frustrate and encourage the client to take responsibility for filling her or his own needs, rather than depending on the clinician (or someone) to fill them. Since overly-dependent and approach-avoid (I want to change / I don't want to change) clients are usually (always?) ruled by a protective false self, this interim technique also aims to help motivate them to eventually do meaningful parts work by compassionately raising their local discomfort.

Participants - the clinician and one or more wounded adult and/or adolescent clients - alone or in a group. This technique is probably not appropriate with (a) a suicidal, homicidal, or criminal client, (b) an addicted client and family, and (c) client-family abuses and/or child neglect.

Best time to do this - when the client's ruling subselves c/overtly hint, expect, or demand that the clinician be responsible for "solving my problem/s," and the clinician feels using this technique is safe enough at this time.

Preparations - clinicians and their supervisor or case manager need to (a) be steadily governed by their true Selves, and fully accept that (b) mentally-competent adult clients are responsible for their own needs, and that (b) it's ethically acceptable to strategically "help by not helping." The clinician also needs (c) a long-range view, and (d) to accept that frustrating the client may cause them to quit this part of their preparing to hit bottom and eventually make second-order changes. Addicted families and clients with toxic compulsions merit special perspective (below). 

Technique - Options:

  • Create some context by asking the client to restate why they have sought professional help, what their key presenting problems are, and what they need - specifically - from the clinician;

  • Recap the work so far, summarizing and affirming progress the client has reported, if any.

  • Verbally summarize (a) the presenting problem the client is depending on you to resolve, and (b) affirm each specific attempt the client has made to resolve it so far.

  • Respectfully acknowledge that these attempts have not solved the problem to the client's satisfaction.

  • Ask (a) if the client can tolerate finding no solution to this presenting problem, and/or (b) "What may happen if you and I can't find a way of making this better for you?" Discuss as needed.

        If appropriate, observe that the client has responded to your interventions on this problem so far with some version of "Yes, but (here's why I can't do that, or why that won't work." Use empathic listening to acknowledge their explanation or defense, and restate something like "So the solutions I've suggested so far don't seem to work for you, do they?"

         Say something like "I'm as frustrated as you are, (name), and I need to be honest - I have no more suggestions for you on this problem. I just don't know what you can do." Listen empathically to any responses, and restate this as often as needed. Then with good eye contact, be quiet and see what the client's subselves need to do. Options:

  • offer a referral to another professional for this presenting problem; and/or...

  • summarize the client's remaining presenting problems, and assure him or her that you do have suggestions on reducing those problems (if true); and/or...

  • propose that...

    • the client is stymied and depending on you on this problem because s/he is probably controlled by a well-meaning false self who doesn't trust his/her true Self to solve this problem, and that...

    • you can offer specific, effective ideas on affirming and resolving this primary problem if the client is interested. Expect ambivalence, disinterest, or polite (dutiful) interest, and "plant seeds." Avoid trying to persuade the client to do parts work, referring to the Serenity Prayer  if/as needed.

  • Do personal parts work if/as needed to maintain serenity with your intervention, including processing this intervention and the client's observed reaction as needed with your supervisor, consultant, and/or case review group.

  • Describe factually what you're doing and why - e.g. "In this case, I want to encourage you to assume responsibility for filling your own needs, rather than postponing that by depending on outside helpers like me. This is a normal, difficult step in helping your subselves to trust your Self and other regular wise subselves to assume full adult responsibility for the quality of your own life."

Next - with the client's agreement, shift to another problem (unfilled need), and/or discuss termination options. If s/he  continues to work with you, follow up in future sessions on her/his response to your "not helping" with this presenting problem. If s/he does assume responsibility for filling related needs, affirm that - regardless of the local outcomes! The real target here is patiently facilitating the client to trust his or her own judgment and competence.

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Updated September 25, 2014