Problems and Strengths
Question 5: When did this problem start?
Sometimes a client can immediately identify a triggering situation. Sometimes she has not thought about whether her difficulties were related to specific changes or events in her life. A series of relatively minor changes, over a short period of time, can equal a lot of stress.
YOUR TURN!
Practice in Your Imagination: Use One of the Five Questions
I want you to imagine using the questions we just covered. Sports psychologists have known for years that imagining practicing a new skill significantly enhances skill development (Weinberg, 2008). It seems to me that if athletes can use imagery to practice, why not therapists?
You can do the exercise by reading along, but I think you will find the exercise more meaningful if you listen to the guided audio file available at the website for this book.
Look at Questions to Explore Your Client’s Problems. Choose a question which you rarely or never use. Now, choose a client with whom you want to try asking this question. Imagine your- self back in your office. Take a moment to look around; notice the sounds and smells of your office. Now imagine yourself asking this question with your client. Now, imagine asking this question with a different client. Each time, imagine that your client responds positively.
Write down the question you choose, and try it with two clients this coming week.
Agenda Item #3 : Meet Suzanne
Throughout this book we are going to follow two clients, Suzanne and Raoul. They are based on a number of my clients and the clients of students I have supervised or taught. I want to start with intro- ducing you to Suzanne. We will meet Raoul later in the chapter.
Suzanne is thirty-four and is married with two young children, Jennifer, age six, and Andrew, age four. She is a fourth-grade teacher and her husband works in a local hardware store. Her husband was her high-school sweetheart, and she is still in love with him. They live in the suburbs of a medium-size city. Her parents and her in-laws live nearby; she sees them regularly and they have a good relationship.
Suzanne’s doctor referred her for therapy because she is always tired and feels chronically over- whelmed by the children, her job, and her other responsibilities. Her physical exam was normal, and her doctor thought it would be helpful for her to “talk to someone.” Suzanne calls the therapist’s office and makes an appointment.
Suzanne is a small, thin woman who smiles timidly when she walks into her therapist’s office for the first time. She perches on the edge of the couch and looks nervously around. When Suzanne’s therapist asks, “How can I help you?” she responds softly with, “I’m not sure… I don’t know even know where to start,” and looks down. Her therapist gently asks, “Tell me what brings you here; I know it can be hard to start.” Suzanne explains she does not know what is wrong with her. She has a great house, great kids, a good job, and a great husband, but she is just so overwhelmed all the time that she isn’t enjoying life anymore. She starts to cry and says she feels like she isn’t coping. Her therapist asks Suzanne to tell her a bit more. Suzanne explains that she is always tired, cries over silly things, and quickly gets angry with the kids. She looks very sad and says, “I’m not even a good mother anymore.”
Suzanne explains that she used to like her job as a fourth-grade teacher, but she dreads going into work these days. She is teaching at a new school, which is a thirty- to forty-minute commute. Her old school was walking distance from home. She is often angry with her husband. He works long hours and she feels she is expected to take care of the children and house without any appreciation from him. She is scared that he will leave her if she stays this depressed. She feels anxious all of the time. She has always been a shy person, but her anxiety is getting much worse; she worries over everything.
Let’s see how we can start to understand Suzanne’s problems using Questions to Explore Your Client’s Problems.
Therapist: Sounds like a lot. I think it would help if we made a list of your problems so we can start to understand them one at a time.
Suzanne’s therapist’s response is both empathic and structured. Suzanne was feeling overwhelmed; her therapist thought that making a list might help her start to feel that her problems were more manageable.
Suzanne lists being tired all of the time, yelling at her children, not doing anything fun, hating work, and wondering if teaching is the right job. These are all general problems, and we don’t really understand how they are affecting her life.
Therapist: I think it would be helpful to understand a bit more about what is happening with you.
Let’s pick one problem and look at it in more depth. Let’s start with exploring what is the worst part of this problem for you. (Question 2)
Note how Suzanne’s therapist explains what she wants to do by saying she wants “to understand a bit more about what is happening with you.” At the same time, she reinforces hope by saying “it would be helpful.”
This is a good example of combining the structure of CBT with creating a good therapy relationship and instilling hope.
Suzanne: I think the worst thing is that I’m always yelling at my kids and feeling like I am not coping.
This is a very general statement. You want a more specific idea of Suzanne’s difficulties. Before looking at Suzanne’s therapist’s response, think about how you could ask Suzanne to identify specific situations that are difficult for her.
Therapist: Could you give me some examples so I have a better idea of the situations that are difficult for you? (Question 1)
Suzanne: Sure, I used to come home and make dinner for the family, and then play with my kids.
These days just making dinner seems to take up all of my energy; I never seem to have time or energy to spend time with my children, and when I do, I am pretty irritated.
As a CBT therapist, you are using the four-factor model to think about your clients’ problems. When Suzanne gave an example of a difficult situation, did she describe her thoughts, feelings, physical reaction, and behaviors?
We have an idea of Suzanne’s feelings (overwhelmed and irritated/angry) and her physical reaction (tired); we don’t know her behavior or her thoughts. She mentioned earlier the thought I am not even a good mother anymore. You can guess that’s what she is thinking about herself in these situations, but it is important to check.
Therapist: Suzanne, when you are feeling overwhelmed and irritated, what are some of the thoughts that are going through your mind? (Question 1)
Notice that Suzanne’s therapist linked her thoughts to her feelings.
Suzanne: I’m usually thinking that I am a terrible mother and the kids deserve better. But I am also thinking that I wish I could just go to bed and not have to take care of the kids.
Try to think of an empathic comment that would summarize what Suzanne said and indicate that you had heard Suzanne’s thoughts. How could you ask Suzanne about her behavior and how she is coping? Think of how you would respond before checking what Suzanne’s therapist said.
Therapist: Those sound like pretty difficult thoughts to be having. Lots of self-critical thoughts and then wishing you could just go to bed and get away from it all. Tell me, how do you cope in these situations? (Question 4)
Suzanne: I just try to control my anger and take care of the kids. But I am pretty short with them. I have been trying to take it easy and go to bed early, to be less tired, but it hasn’t helped.
Therapist: Have you tried anything that has helped?
Suzanne: No, not really.
How could you introduce Question 3?
Therapist: I wonder if there are things you have stopped doing since you have been feeling so bad, or situations you are avoiding?
Suzanne: Well, I generally do less fun things with my husband and children. Lately I am just too tired.
This is a very general comment. How could you help Suzanne become more specific about what “fun things” she is doing less of?
Therapist: When you say you do less fun things with your husband and children, can you give me some examples?
Suzanne: I used to take my daughter, who is six, to a playgroup in the afternoon with some of my neighbors. I have a half day off from work each week. But I’ve been too tired to do that.
Also my husband and I used to take the kids to the park on weekends, which was a fun family time; but I often send them over to my parents’ so that I can nap, or my husband takes them without me.
When you look at Suzanne’s response, is there anything Suzanne has been doing more of? Suzanne’s thera- pist thought that she had been doing more resting and napping. This is a good place to ask about changes in alcohol consumption, drugs, and medication.
Her therapist discovers that Suzanne has stopped doing most afterschool activities with her chil- dren as she is “too tired” and that she has also stopped seeing and talking with most of her girlfriends.
She and her husband have also stopped seeing many of their friends and family because Suzanne feels that she is too tired. Suzanne’s problems started when she changed schools. She is unhappy at her new school, has made no friends, and feels like an outsider. Suzanne has not started consuming alcohol, nor did she report abusing prescription or nonprescription medication.
Suzanne’s therapist suggested that they write down a preliminary list of the problems that Suzanne would like to work on in therapy.
Suzanne suggested the following problems:
1. Not having any friends at my new school 2. Yelling at my children and husband 3. Being tired all of the time
4. Not doing fun things with my husband and children
5. Being depressed and anxious and just not enjoying life anymore 6. Wondering if teaching is the right job for me
This is a long list; the therapist and Suzanne have to figure out where to start.
Collaboratively decide which problem(s) your client wants to start working on in therapy. If you remember from earlier in the chapter, there are three main steps to obtaining an initial understanding of your client’s problems. First, ask about your client’s problems and make a list; second, explore how your client’s problems are affecting her life; and third, collaboratively decide which problem your client wants to start working on. We are now ready for the third step.
Some clients come to therapy with one main problem, but most have a number of different prob- lems. You and your client need to decide which problem to address first, or therapy can feel like wander- ing around without a focus. The easiest approach is to be direct and say, “I think it’s helpful to try and address one problem at a time. When we look over your problem list, which problem would you like to start with?” You want to pick a problem where there is a good chance you can help your client fairly quickly and that will have an immediate impact on her life.
Marsha Linehan (1993) suggested some very useful criteria for prioritizing your client’s problems.
First, if your client is actively suicidal, your first priority is to make sure that she is safe. Second, if your client is behaving in a manner that is dangerous or that is likely to significantly interfere with her life, these behaviors need to be addressed. Examples of these types of behavior include major substance abuse, missing work or school, and being involved in a physically or emotionally abusive relationship.
In addition, if a client regularly engages in behavior that interferes with therapy, for example, coming late to therapy, insulting the therapist, or skipping sessions, these behaviors need to be addressed.
If we consider each of Suzanne’s problems, the first four that she listed are more specific and con- crete than being depressed and not enjoying life anymore or wondering whether teaching is the right job for her. The therapist explained to Suzanne that because the first four problems are more specific and concrete, she would want to start with one of these so she will be able to help Suzanne in a shorter period of time and with more focus to therapy. She then asked Suzanne which problem she wanted to start with. Suzanne wanted to start with making friends at her new school and not doing any fun things with her husband and children.
Video 2.1: Meet John and Understand Your Client’s Presenting Problem
Agenda Item #4: Understand Your Client’s Stressors and Strengths
In addition to understanding your client’s presenting problems, you need to understand how these problems fit into her overall life. You want a picture of her current life, how she is functioning, and any other stressors or difficulties in her life besides her presenting problem, as well as the positive supports in her life and her areas of strengths.
You can introduce this section by saying, “I am starting to get an understanding of your problems.
I think it would be helpful if I could also get a sense of other parts of your life.” Notice that I explain what I will be doing and indicate that it will be helpful to my client.
The basic categories that I ask about are family, friends and social contacts, recreation and involve- ment in organizations outside of the home, work or school, health, and finances. Finances includes the ability to budget, pay bills on time, and all that is involved in being financially responsible. When
asking about health, if you did not already ask about alcohol and drug use, this is a good place to do so.
I also ask about self-care, either under recreation or health. I want to know if my client is engaging in activities that are nurturing for her and if she is participating in any regular exercise. In addition, I ask whether over the past year or few years there have been any major changes in my client’s life, or a number of small changes.