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
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.
+ + +
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
their underlying unfilled
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:
-
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...
-
adults unaware of being dominated by a well-meaning
and...
-
ineffective
and
and possibly...
-
incomplete or
in one or more family members, stemming from an ineffective family
which inhibits these
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
in any involved professionals,
-
conflicting
attitudes (values conflicts) among professionals;
-
major differences over...
-
using
assessments and interventions,
vs. more psychoanalytic, client-centered (Rogerian), brief therapy,
problem-focused, and medical-model paradigms;
-
using
- 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
(vs. religion) in the work; and...
-
different perceptions of typical
divorcing-family and stepfamily basics,
and
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
these differences because they (a) are significantly wounded and in denial,
and (b) lack
and
basics and
Effective
clinical service with
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]
continuing to spread and weaken our society.
Pause and
reflect on what you just read. If you fully accept the clinical
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
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
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
-
do key family adults need education on the
[wounds + ignorance]
and its common
-
If anyone in the family was or is
have they hit true (vs. pseudo)
yet? If so, are they in true, stable addiction-recovery ("sobriety") yet?
-
(a) how
is each family adult and key supporter, (b) have they hit true bottom
yet, and (c) if so, are they in true
wound-
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
and
- 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
-
Do family adults need education on
healthy grief, and...
-
do any family
members show
of
incomplete or blocked grief? If so...
-
what is this family's (unspoken)
and who makes
and enforces it?
-
If the family includes minor kids, (a) do
co-parents need education on
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
below their surface problems to discern their unfilled
-
If circumstances allow, also assess
whether the family is stressed by
and/or
conflicts,
and associated
If so, see if and how these may
contribute to the client's presenting problems.
Limited Assessment of
(GWCs)
See to
learn the following information within existing clinical constraints:
-
What caused this person to seek clinical help?
-
If s/he has hit
when and how?
-
how often is her or his true Self
in (a) calm and (b) stressful times now? (never > seldom > often > always)
-
Is s/he receptive (vs. resistant or ambivalent)
to the idea of
and false-self
If not, is she willing to (a) try this safe
experience, and (b) read this letter?
-
If s/he was or is
-
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
his or her true Self to lead and harmonize their
can promote that, vs. on wound -recovery.
-
what are his or her demonstrated vs. stated
current life
(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
(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
-
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
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
and
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
you need?
+ + +
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The Web address of this article is https://sfhelp.org/pro/spl/limited.htm