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

Optimizing Clinical Outcomes
when Sessions are Limited

By Peter K. Gerlach, MSW

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  • site intro > course outline > Lesson 6 study guide or links > site search or chat, or prior page > here

  The Web address of this article is http://sfhelp.org/pro/spl/limited.htm

        Clicking links here will open a new window or an informational popup, so turn off your browser's popup blocker or accept popups from this nonprofit, ad-free site . If the windows distract you, read the article before following any links.

        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:

  • The intro to this nonprofit Web site and the premises underlying it

  • self-improvement Lessons 1 thru 8

  • These clinical and lay terms

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

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       This article for clinicians...

  • summarizes the challenge with time-limits to working with multi-problem, low-nurturance clients;

  • describes common professional conflicts to resolve before providing clinical service,

  • proposes key assessment targets for most time-limited cases, and...

  • suggests guidelines for optimizing interventions within the time constraints.

The article assumes you are familiar with (a) the general traits of divorcing family and stepfamily clients, and (b) the key points in this clinical model of working effectively with them. If not, first study Lessons 1 thru 7 here.  

study...

these terms and definitions used here; and...

this introduction to effective clinical service, and the overview of this clinical model; and...

these overviews of (a) clinician requisites and (b) effective client-assessments and interventions.

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What's the Problem?

        Typical divorcing-family and stepfamily systems are (a) structurally and dynamically complex, (b) multi-problem, and (c) often have low nurturance levels. They usually have a cluster of concurrent, inter-active stressors that require many clinical sessions to iteratively assess and reduce. When insurance coverage limits the number of hours or sessions the client can use, clinicians must prioritize  their goals and interventions.

        Service limitations require clinicians to prioritize (a) the client's and (b) her or his own goals, and se-lect those that can reasonably be achieved within in the case constraints. Ethically, the clinician owes the client and their funder/s and other involved professionals an honest appraisal of what's needed, what's  possible, and what isn't, within case limitations.

       A high percentage of clinical work with typical low-nurturance (wounded, unaware) clients is (a) as-sessing clients' knowledge of key topics, (b) providing appropriate education, and (c) motivating clients to use it to reduce their presenting problems. Limited-service cases put higher value on the clinician provi-ding appropriate written educational materials and/or references, rather than teaching and modeling them in person.

        Typically, low-nurturance and wounded clients will not know or ask for what they really need as per-sons, mates, and as a family. Commonly, their presenting problems - specially if adults are governed by false selves - are superficial, because the client adults don't know why or how to discern their  underlying unfilled  primary needs. Teaching and motivating clients why and how to discern these needs and how to fill them effectively become primary clinical goals.

Five Clinical Goals

        Tho every case is unique, this model proposes four or five clinical goals that pertain to most wounded persons and low-nurturance clients:

  • crisis stabilization and management, when needed,

  • acknowledging the client's presenting (surface) problems;

  • educating the participating family members to accept that these surface problems probably result from...

    • wounded adults unaware of being dominated by a well-meaning false self; and...

    • ineffective communication and problem-solving, and possibly...

    • incomplete or blocked grief in one or more family members, stemming from an ineffective family grieving policy which inhibits these requisites for healthy mourning.

This framework allows focusing limited clinical sessions on the most important issues in the order shown.

        Before summarizing assessment and intervention guidelines following this limited-service framework, let's look at...

Likely Professional Conflicts

        The model on which the framework above is based is unconventional, so veteran clinicians and administrators will probably find parts of it alien and questionable. This may promote significant disagreements between clinicians and their supervisors, case managers, program directors, and/or funders over how to prioritize clinical goals and strategies. Probable primary disagreements will span a mix of topics like these...

  • significant false-self wounding in any involved professionals,

  • conflicting attitudes (values conflicts) among professionals;

  • major differences over...

    • using systemic assessments and interventions, vs. more psychoanalytic, client-centered (Rogerian), brief therapy, problem-focused, and medical-model paradigms;

    • using this model - specially over accepting the core reality of personality subselves; and...

    • fluidly combining intrapsychic, dyadic, and family treatment modalities as needed; and...

  • differences over the importance and role of personal and family spirituality (vs. religion) in the work; and...

  • different perceptions of typical divorcing-family and stepfamily basics, stressors, and primary needs, and... 

  • disputes over the client's primary needs, regardless of their family-type and/or presenting problems; and...

  • differences over what constitutes a high-nurturance clinical program or agency, and...

  • opposed professionals being unable to resolve or calmly accept these differences because they (a) are significantly wounded and in denial, and (b) lack communication and problem-solving basics and skills.

        Effective clinical service with these clients requires conflicted professionals to honestly admit and effectively reduce their disputes early in the work. This is most likely in high-nurturance professional organizations and systems. If you experience major professional disagreements like these and the people involved avoid effective negotiation and resolution,

        I propose that you're working in a low-nurturance setting. If so, this (a) inhibits any personal recovery you may need, (b) inherently provides moderate clinical service to low-nurturance clients at best, and (c) promotes the silent [wounds + unawareness] cycle continuing to spread and weaken our society.

        Pause and reflect on what you just read. If you fully accept the clinical model proposed here, what's your attitude about confronting such professional disagreements before serving low-nurturance clients? If you don't accept this model, (a) who controls your personality, and (b) why are you reading this?

        Before reading further, reflect and say out loud your present values and practices about assessing and intervening with multi-problem clients when contact hours or sessions are limited. Start with your definition of "effective clinical service" in this situation.

Assessment Guidelines

        In time-limited cases, this model proposes priority assessment targets. Some of this information can be learned from a well-designed intake form and/or interview:

  • (a) what type of client is this, (b) who referred them, and (c) why are they seeking clinical help (what are their presenting problems)?

  • (a) who comprises their family system, and (b) do family members agree on this?

For Couples and Family Clients:

  • How stable and functional is this family's structure?

  • do key family adults need education on the [wounds + ignorance] cycle and its common effects?

  • If anyone in the family was or is addicted, have they hit true (vs. pseudo) bottom yet? If so, are they in true, stable addiction-recovery ("sobriety") yet?

  • (a) how wounded is each family adult and key supporter, (b) have they hit true bottom yet, and (c) if so, are they in true wound- recovery yet? See these basic Lesson-1 assessments for options.

  • (a) who makes the family's decisions and (b) how - e.g. democratically, autocratically, impulsively, well-discussed and planned, reactively, etc.?
     

  • How open are the client adults to making second-order (basic attitude) changes?

  • How (a) knowledgeable and (b) effective are the key adults at communicating and problem-solving  - generally and in significant conflicts and uproar? See these basic Lesson-2 assessments for options.

  • What are the key strengths and stressors in selected or all primary adult relationships in the client family, including personal and shared spirituality? How adept are they at permanently resolving relationship problems (filling their respective primary needs)?

  • What are key family adults' stated and demonstrated recent priorities?

    • Do family adults need education on healthy grief, and...

    • do any family members show symptoms of incomplete or blocked grief? If so...

    • what is this family's (unspoken) grieving policy, and who makes and enforces it?

  • If the family includes minor kids, (a) do co-parents need education on effective child-nurturance?; and (b) how effective are the co-parenting adults at identifying and filling kids developmental and family-adjustment needs?

  • Are the client adults open to learning how to dig down below their surface problems to discern their unfilled primary needs?

  • If circumstances allow, also assess whether the family is stressed by loyalty and/or values conflicts, and associated relationship triangles. If so, see if and how these may contribute to the client's presenting problems.

Limited Assessment of Grown Wounded Children (GWCs)

        See to learn the following information within existing clinical constraints:

  • What caused this person to seek clinical help?

  • If s/he has hit true bottom, when and how?

  • how often is her or his true Self in charge, in (a) calm and (b) stressful times now? (never > seldom > often > always)

  • Is s/he receptive (vs. resistant or ambivalent) to the idea of personality subselves and false-self wounds? If not, is she willing to (a) try this safe experience, and (b) read this letter?

  • If s/he was or is addicted:

    • to what (substances, activities, relationships, and/or mood-states)?,

    • what has s/he tried to manage the addictions?

    • If s/he has attained sobriety, for how long, and...

    • does s/he attend any relevant 12-step program now?

    If s/he hasn't maintained sobriety for at least six months, focus on how freeing his or her true Self to lead and harmonize their other subselves can promote that, vs. on wound -recovery.

  • what are his or her demonstrated vs. stated current life priorities? (How high does wound-recovery rank?)

  • How supportive is this client's social environment (family, friends, any church community, and workplace  or school) to personal wound-recovery (low to high)?

  • Is s/he in true (vs. pseudo) wound-recovery yet?

  • If s/he has relapsed, when and why?

  • Is s/he willing to try some version of parts work (inner-family therapy)?

  • Is s/he willing to inventory his or her personality subselves? If so, which subselves are causing the client's main presenting problems?

  • Is s/he willing to try dialogs with her or his personality subselves? If so, how does s/he react?

  • Is s/he willing to assess which psychological wounds s/he has, and how they affect her or his life and any dependent kids?

Optimize Interventions

        The clients served by this model are usually significantly wounded and unaware, and have multiple concurrent presenting and primary needs. When service is limited, qualified clinicians can seek progress on the five goals above, in the order shown. "Progress" here means...

  • motivating clients to study and apply the selected topics,

  • illustrating how the topics promote the client's presenting (surface) problems, and...

  • making realistic suggestions about the potential long-term benefits of further clinical work.

intervening to cause significant second-order client-system changes is probably unrealistic.

        This model suggests the two most productive universal topics to teach clients are (a) the normalcy and significance of personality subselves and psychological wounds, and (b) effective thinking, communicating, and problem-solving skills. As session-time permits, tailor Lesson-1 and Lesson-2 interventions to help clients learn and apply these vital, inter-related topics.

        Because these related topics apply to all low-nurturance clients, a cost-effective way to alert and interest them is by offering (a) educational handouts (e.g. selected articles in this site or equivalent), and (b) affordable, accessible seminars on both topics.

       Option - suggest that clients invest in one or both of the Lesson-1 and Lesson 2 guidebooks for ongoing education, practical applications and options, and ready reference,

        For courting or committed stepfamily clients who are progressing on learning about wound-recovery and effective communication and grieving - suggest their family adults (a) adopt a long-term view and the open mind of students, and (b) commit to tailoring a learning program for all their members on stepfamily facts, basics, hazards, problems, and Projects. 

Recap

        When program or insurance constraints, and/or client motivation or resources, limit service, clini-cians using this model must select priority assessment and intervention targets for optimal (limited) outcomes. This article...

  • summarizes this challenge,

  • describes common disputes clinicians must resolve before providing effective limited service,

  • proposes key assessment targets for low-nurturance clients and Grown Wounded Children (GWCs); and...

  • suggests optimal limited-intervention strategies with these clients.

        Pause, breathe, and reflect: Did you get what you needed from reading this article? If so, what do you need to do next? If not, what do you need?

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Updated 09-30-2015