Client Intervention Planning Exercise.

Client Intervention Planning Exercise

Article by Steve Andreas

Many approaches to therapy are purely, or mostly, reactive. The classic example is Freud’s analytic method of sitting behind the couch out of sight of the client, quietly listening, and only occasionally making interpretations about what the client says. Carl Rogers listened and reflected back the words and feelings that clients expressed, in what was called “non-directive listening,” or “active listening.” In many other current approaches, the therapist allows the client to talk freely, and responds to what they say. These approaches usually result in a wandering dialogue that may have little relevance to the client’s outcome — what Fritz Perls often called “free dissociation.”

However, master therapists such as Milton Erickson, Fritz Perls and Virginia Satir were very, very active in interrupting the client’s problem trance state. And they used injunctive language — “Do this,” “Try this” — to elicit alternate states and understandings that were more useful. Erickson used overt hypnosis to create alternate realities, while Satir used her personal expressiveness and role-plays to achieve similar effects without overt hypnosis — and she didn’t like hypnosis. However, an instruction such as, “Get down on your knees to show that you are little,” was a pretty explicit instruction for age regression, a classic hypnotic method. Perls used the “empty chair” to embody troublesome people and events from the client’s past, evoking not only age regression, but what is supposedly one of the most difficult of hypnotic phenomena, positive hallucination, simply by saying, “Put your mother in the chair; what would she say?”

These therapists also deliberately planned the sequence of what they expected to do in a session to reach the client’s outcome, while at the same time respecting, utilizing, and responding to whatever the client did in the session.

In this article I want to present a description of what a client presented to a therapist, ask you to pause to consider what you might do, and make a “treatment plan” outline of what you would do with him.
In a recent article in the Psychotherapy Networker magazine, “Living with the Devil You Know,” (January/February 2013) David Burns describes a client, Sam, who had been working in a fast food outlet six months earlier:

“One night, just before he closed up, two gunmen robbed the place. Before they left, they threw Sam into a walk-in freezer and left him there to die, laughing on the way out about the clever thing they’d done. The next morning, the manager came in early and was alarmed to see the doors open and the lights still on. When he opened the freezer, he found Sam huddled in a corner and shivering, but still alive.

“Although he’d survived, Sam was badly traumatized. He soon developed panic and rage attacks, and spent most of his waking hours haunted by vivid memories of the incident. He constantly worried that it would happen again, and woke up at night from terrible nightmares. When he wasn’t struggling with flashbacks or worrying about getting mugged again, he imagined finding the men and taking revenge on them. He said the anger and panic had totally consumed his life. All he wanted, he told me, was to get his life back, if that was possible, though he doubted it was.”

Imagine that Sam came into your office, and had just told you this. What ideas do you have about what you might do with him to achieve his outcomes? Recognizing that what you would do might change as you proceed, develop a tentative treatment plan.

Take a few minutes to think about what you would do, and in what order. What would you do with Sam first, . . . and what next, . . . etc., and make a few brief notes as a reminder to compare with the discussion that follows below . . . .

The outline below is only one of many, many, possibilities that could be useful. It is my best guess about a useful sequence that would give Sam a set ofexperiences that would be life-changing, and reach his stated outcomes. In what follows, the specific words are much less important than the principles they embody.

1. Whatever you did next, the first thing to do is to acknowledge and reflect his experience, so that he knows that you understand it fully, using an appropriate voice tone and emphasis, “That must have been truly horrible, spending all those hours in the cold, sure that you were slowly freezing to death!” — while monitoring his nonverbal response for signs of agreement.

In contrast, many therapists might say something like “I understand,” in a neutral tone of voice that would be weak and unconvincing to he client.

2. Then if you go on to say something about his experience that he didn’t tell you — and he may not have even thought of — yet that he is almost certain to agree with, he will feel even more fully understood. “It is one thing to die quickly from a gunshot to the heart; it is quite another to die agonizingly slowly over a period of many hours!” again monitoring his nonverbal response to confirm that he is responding with agreement. By saying this, you are not just accepting his experience, but amplifying it, fully acknowledging his horror — while at the same time offering an alternative scenario of what could have happened but didn’t, providing a different comparison that creates an alternate perspective.

3. Assuming that he was responding fully to what I said, next I would say, in a much more “upbeat” tone of voice, “And I wonder if you fully realize how verylucky you are.” This is an example of a hypnotic linguistic form called an “embedded question.” Although it is actually a statement, people typically respond as if it were a question to be answered. However, since it is not an overt question that demands a verbal answer, it is an invitation to “go internal” into a mini-trance and respond to it silently. This sentence also presupposesthat he is lucky; the question is only whether or not he realizes it, and most likely he doesn’t — in fact what I said is probably very surprising and confusing to him. Since I have already agreed with him so fully, he has to consider it and try to figure out the apparent contradiction. If I had said this without previously agreeing with him, he would only have gotten very angry and probably walked out.

4. I would continue to make eye contact, while observing his response, which is almost guaranteed to be a mixture of shock, astonishment and incredulity! A moment before I had completely agreed with his experience; now I am saying something that apparently completely disagrees with it. He has undoubtedly been feeling very unlucky to have been mugged; how can I possibly say that he is very lucky!? His state of misery about his memory of being mugged has been completely interrupted; now he is in a very different state of confusion and intense curiosity about what I said, and how it could possibly make sense. This state of confusion and curiosity creates an openness to consider whatever I say next, because it promises a resolution of his confusion.

5. I would continue to wait patiently for him to process this, and wait for him to ask for some explanation. It doesn’t really matter what he says, but it is very important that I wait for him to actively seek an explanation, because asking increases his readiness to listen to and process what I say next. “How on earth can you say that I’m very lucky?!”

6. “Those robbers locked you in the freezer, expecting that you would die, and even laughed in cold-blood about it, and how clever they were. What do you suppose they would have done to you if they hadn’t locked you in the freezer?” This question is an indirect hypnotic command to make images of various other ways that they could have killed him — and one of them is almost certain to be the image that I deliberately planted earlier — a “gunshot to the heart.”

7. Again I would pause to watch him process this and respond to it. Notice that the earlier reference to the gunshot was that it was faster than freezing; now I am implicitly asking him to notice that the same image is much morepermanent, using a different criterion to evaluate the same imagined event — one of the many patterns of reframing.

Discussion:

Regardless of what he says or does next, he now has at least one alternative horror scenario to compare what actually happened to him. In comparison to dying instantly from a gunshot, spending the night in the freezer with no permanent damage probably doesn’t seem quite as bad as it did in isolation. Moreover, this horrible alternative is tightly coupled in his mind to his memory of being in the freezer; from now on he can’t think of the freezer without thinking of being shot in the heart, giving him a much more balanced view. I call this the “Maurice Chevalier move,” because when someone asked Chevalier what it was like to be old, he replied, “Not bad — particularly when you consider the alternative!”

Again, this scenario is only one of a multitude of possibilities, and it isn’t guaranteed to work with everyone; I am using it only as an example to point out the importance of using your voice tone and other nonverbal expressiveness to create experiences that will likely impact the client and change his/her response in a useful way.

Now let’s go back to the beginning, and imagine that after listening to Sam’s statement of his problem, I had said, “You were really lucky they didn’t shoot you,” and imagine his response in your mind’s eye. Although that sentence is an accurate summary of what I have just described, its only impact would be proof that I didn’t understand his experience at all!

It is useful to think about the sequence of your interventions, and more important, use all your nonverbal expressiveness to create a vivid experiencethat will impact the client. However, most therapy training doesn’t include any improvisational theater or other acting training that would teach how to use nonverbal behavior to elicit feeling responses in others.

When Sam came in, he was totally immersed in his horrible memory and it had “totally consumed his life”; now his broader perspective reduces the intensity of his response, and it will be much easier for him to focus on the issues he mentioned initially:

1. His vivid horrible memories, nightmares and flashbacks,
2. His anxiety and panic about being mugged again in the future,
3. His anger at the robbers and desire for revenge.

These would probably best be dealt with in the order presented, because his anxiety results from his horrible memories, and his anger results from both his memories and his anxiety.

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