Fall 2024 SOWK 581 Week 03 - The Clinical Interview Process

Fall 2024 SOWK 581 Week 03 - The Clinical Interview Process

title: Fall 2024 SOWK 581 Week 03 - The Clinical Interview Process date: 2024-09-06 17:32:00 location: Heritage University tags:

• Heritage University
• MSW Program
• SOWK 581 presentation_video: description: > Week three will be synchronous, with a class on Saturday (09/07/24). The topic for this week is the clinical interview process. The agenda for the in-person sessions will be
• Overview of the clinical interview process
• What happens in the beginning stage of treatment
• Transference and countertransference
• Practice exercise with motivational interviewing
• Middle and end of treatment Learning Objectives
• Consider a case example and the clinical interview process with them.
• Define the concepts of transference and countertransference.
• Understand the stages of change model of treatment.
• Explain some of the considerations in the different phases of the treatment process.
• Experience a conversation that is not motivational interviewing and one that is more in line with motivational interviewing.
• Develop insight into your own intersectionality.

Agenda and Learning Objectives

Agenda

• Overview of the clinical interview process
• What happens in the beginning stage of treatment
• Transference and countertransference
• Practice exercise with motivational interviewing
• Middle and end of treatment Learning Objectives
• Define the concepts of transference and countertransference.
• Understand the stages of change model of treatment.
• Explain some of the considerations in the different phases of the treatment process.
• Experience a conversation that is not motivational interviewing and one that is more in line with motivational interviewing.
• Develop insight into your own intersectionality.

Overview of Clinical Interview Process

I want to start off by thinking in a broad overview of the clinical interview process. I appreciate the textbook author using the framing beginning, middle, and end. Depending on when you took your BASW practice classes, if you used the Hepworth et al. textbook they frame it. Phase 1: Exploration, Engagement, Assessment, and Planning Phase II: Implementation and Goal Attainment Phase III: Evaluation and Termination Or if you used the Kirst-Ashman and Hull generalist practice model: Engagement Assessment Planning Implementation Evaluation Termination Follow up One of the things that I think is interesting in how the Cooper and Granucci Lesser (2022) make the connection to the stages of change (which they describe as a Transtheoretical Model) The stages of change model uses interventions from several theoretical models and is therefore called transtheoretical. (p. 24) The Beginning of Treatment:

• Pre-contemplation
• Contemplation* The Middle of Treatment
• Contemplation (this is where they put it)
• Preparation
• Action The Ending of Treatment
• Maintenance
• Termination

Beginning stages of treatment (1 of 3)

I think something important for us consider at the start of treatment is the referral source. Mandated vs Voluntary [Whole Class Discussion] What should we be thinking about if a client is mandated verses voluntary.

Beginning stages of treatment (2 of 3)

Your textbook goes through and discusses what the start of the treatment usually includes. There are opportunities for introductions, potentially having clients ask personal questions, working to understand the your own and the clients self-awareness, and sharing about confidentiality that happen in the first session. Also during the first session is when you start doing your assessment and understand why the client is here. [Whole class/Small Group Activity] Talk about each of these as described below:

• The first meeting (elicit experiences with the first meeting a client)
• Confidentiality (have one person share how they describe confidentiality, then everybody do with a partner)
• Introductions (brainstorm what should be described in our introduction, and then everybody do it with a partner)
• Answering personal questions (how do we handle this, any examples people have?)

Beginning stages of treatment (3 of 3)

Self-awareness is an umbrella term. Within the context of the clinical interview, we relate self awareness to an understanding of the multiple dimensions of the worker’s identity and how that interacts with the multiple dimensions of the client’s identity. (Cooper & Granucci Lesser, 2022 p. 19) [Small Group Activity] With a partner, ask each other the same question a number of times; the same answer cannot be used twice. The questions they ask each other (changing roles) are “Who are you?” and “Who do you see?”

Therapeutic relationship

I want to move into talking some about the therapeutic relationship. This goes through all three of the phases, but will look differently in each one. Some of the things we think about are:

• Transference and countertransference
• Working alliance and the real relationship
• Resistance
• MI and Stages of change

Transference and Countertransference/Intersubjectivity

Transferance and Countertransference are important in understanding the therapeutic relationship. Lets start with defining them. Transference: A client’s transferential responses may be evoked by the therapist. Countertransference/Intersubjectivity: Considered to be both the result of the therapist’s unconscious processes and an appropriate reaction by the therapist to the patient. It is a reciprocal influence of the conscious and unconscious subjectivities in the therapeutic relationship. [Whole Class Activity] What do you think these might look like. How do we handle it.

Persuasion Exercise

Purpose: To provide an experiential contrast to motivational interviewing. In preparation for learning an interpersonal skill, trainees experience first-hand what happens when the opposite approach is taken. This exercise is designed to raise trainees’ awareness of common responses that are not reflective listening or motivational interviewing, and how they can obstruct motivation and change. Usually this exercise generates quite a bit of laughter. Group Size: 3: Trainer plus 2 trainees add 1 as observer if needed Total Time: 15 minutes The session will automatically end after 15 minutes. Trainer: You will work with a pair of trainees. Decide which will be Speaker and Helper first; they will then switch roles. Give instructions in your own words. If you have three trainees, assign one to simply observe on the first round, then they participate in the second round while another trainee observes. Instructions for Speaker: “I would like you to talk about something you have been thinking about changing in your own life. It could be a habit, attitude or behavior, but it should be something you haven’t changed yet. Maybe it’s something that would be good for you, or that you think you should change. It should be something you feel comfortable sharing – not your deepest, darkest secret, okay? Any questions about that?” Instructions for Helper: “Your task is to try as hard as you can to convince and persuade the Speaker to make the change that he or she is considering. Specifically, once you find out what the change is that the person is considering, do these five things:

1. Explain why the person should make this change.
2. Give at least three specific benefits that could result from making the change.
3. Tell the person how they could make the change.
4. Emphasize how important it is for them to make the change. This might include the negative consequences of not doing it.
5. Tell/persuade the person to do it. And if you encounter resistance, repeat the above, perhaps more emphatically.” Guidelines: Mention that this is not motivational interviewing. Your instructions should take no more than 3-4 minutes, and give instructions as if trainees do not already know what to do. When you start the first pair, use your watch to time 4-5 minutes, then stop the conversation and have them reverse roles. Again allow 4-5 minutes for the Helper to “help.” If time remains, have Speakers describe what they were experiencing during the conversation. We will then have a short debrief as a whole group. Trainees: When you are the Speaker, use one of your “a change I am considering making” topics. When you are the Helper, follow precisely the instructions given to you by the trainer. Do not use reflective listening. Within 4-5 minutes, try to fit in all five of the instructions. Reference: Miller, W. R. & Moyers, T. B. (2020, October 26) Training for New Trainers (TNT) for the International Motivational Interviewing Network of Trainers (MINT): Practice Exercise Guidelines for Participant Trainers. https://motivationalinterviewing.org/sites/default/files/training_exercise_handouts.pdf

A Taste of Motivational Interviewing

Purpose: This offers both Speaker and Interviewer an experience of an MI conversation. This can be done early in training, and it is not necessary to explain MI in advance or why these particular questions are used. This works well as a contrast after a Negative Practice exercise like #2. Group Size: 3-4: Trainer plus 2 trainees add 1 as observer if needed Total Time: 20 minutes The session will automatically end after 20 minutes. Trainer: You will work with a pair of trainees. Decide who will be Speaker and Interviewer first; they will then switch roles. Give instructions in your own words. If you have three trainees, assign one to simply observe on the first round, then they participate in the second round while another trainee observes. Instructions for Speaker: “I would like you to talk about a change that you are considering, something you are thinking about changing in your life, but have not definitely decided. It will be something you feel two ways about. It might be a change that would be “good for you,” that you “should” make for some reason, but haven’t done yet. Tell the interviewer about this change you are considering. Instructions for Interviewer: Don’t try to persuade or fix anything. Don’t offer advice. Instead ask these four questions one at a time, and listen carefully to what the person says:

1. Why would you want to make this change?
2. If you did decide to make this change, how might you go about it in order to succeed?
3. What are the three best reasons for you to do it?
4. How important would you say it is for you to make this change, on a scale from 0 to 10, where 0 is not at all important, and 10 is extremely important? [Follow-up question: And why are you at _____ rather than a lower number or 0?] After you have listened carefully to the answers to these questions, give back a short summary of what you heard, of the person’s motivations for change. Then ask one more question:
5. So what do you think you’ll do? and listen with interest to the answer. Guidelines: Your instructions should take no more than 3-4 minutes, and give instructions as if trainees do not already know what to do. When you start the first pair, use your watch to time 6-7 minutes, then stop the conversation and have them reverse roles. Allow the next Interviewer 6-7 minutes to ask the questions and summarize. You may need to keep this conversation on track if the Interviewer or Speaker wander away from the structure. The “how important” question often needs a bit of guidance, particularly in relation to asking the follow-up question. If needed, after the four questions have been asked, remind the Interviewer to offer a short summary of the Speaker’s motivations for change. Then, if needed, guide the Interviewer to the fifth question. You will continue as Trainer with Exercise #4 – Debrief by Evoking. Trainees: When you are the Speaker, use one of your “a change I am considering making” topics. When you are the Interviewer, follow precisely the instructions given to you by the trainer. You may offer a reflective listening response, if appropriate, after the Speaker answers a question. To give the trainer something to do, wander off the assigned task once.

MI Strategies: OARS

If I have too much time, teach about OARS, demonstrate it, and have people practice Taken from: https://rutgerstraining.sph.rutgers.edu/Fiveminutes/download/mi_strategies_cheat_sheet.pdf Photo by Jake Lorefice on Unsplash OARS represents communication strategies that can help a practitioner elicit change talk from the client/patient. It is an essential part of MI that should be utilized during the Brief Intervention (BI) portion of SBIRT to enhance motivation. OARS stands for the following:

1. O pen-Ended Questions
2. Personal A ffirmations
3. Listen & Engage in R eflections
4. Provide S ummaries OPEN-ENDED QUESTIONS
   • Open the door and encourage the client to talk: “Can you tell me what you like about using?”
   • Do not invite a short answer: “What makes you think it might be time for a change?”
   • Leave broad latitude for how to respond: “Can you tell me more about how this began?” PERSONAL AFFIRMATIONS
   • Commenting positively on an attribute: “You’re a strong person, a real survivor.”
   • A statement of appreciation: “I appreciate your openness and honesty today.”
   • Catch the person doing something right: “Thank you for coming in today!”
   • A compliment: “I like the way you said that.”
   • An expression of hope, caring, or support: “I hope this weekend goes well for you!” LISTEN & ENGAGE IN REFLECTIONS
   • Are statements rather than questions:
   • Question: “Do you mean that you’re wondering if it’s possible for you to cut down?”
   • Reflection: “You’re wondering if it’s possible for you to cut down.” - Make a guess about the client’s meaning (rather than asking) - Yield more information and better understanding - Often a question can be turned into a reflection - Helps the client/patient continue exploring - In general, a reflection should not be longer than the patient/client’s statement PROVIDE SUMMARIES
5. Collect material that has been offered: “So far, you’ve expressed concern about your children, saving money, and providing a stable living environment for your family.”
6. Link to something just said with something discussed earlier: “That sounds a bit like what you told me earlier about feeling lonely.”
7. Draw together what happened and transition to a new task: “Before I provide you with some referral recommendations, let me summarize what you’ve told me so far, and see if I’ve missed anything important….Is there anything else that you would like to add before we move on?”

The Middle Stage of Treatment

The middle stage of of treatment is generally the longest, most productive, but also when clients can lose interest and terminate without a planing to. As a side note, I really liked the example they shared in the textbook. A good realistic case example. Exploring the reality—the real relationship—will help the worker adjust to client needs. A client may be justifiably angry with a worker for numerous reasons. Perhaps he was inattentive, unempathetic, or preoccupied. Something as seemingly slight as answering the phone during a client’s session may feel like a lack of empathy and produce a strong reaction from the client. You may not hear the reaction right away, but subsequent sessions will provide clues. The skilled worker pays sharp attention during the middle phase to the client’s verbal and nonverbal behaviors. It is completely appropriate to mention, for example, that the client seems less talkative, or more edgy, or that something seems different. This is not to be confused with confrontation. Direct confrontation can be offensive and angering to a client, with the exception of those who have or are participating in recovery programs where confrontation is the norm. It is much better to gently comment that it seems hard for the client to talk about something, or to respond to your words, than to rush headlong with an interpretation such as “You are angry that I’m talking about your past.” Interpretations often feel like wounds, especially if they are made too early in the work. And they can often be incorrect. It is more appropriate to explore and let the client come up with the meaning for herself.
Cooper, Marlene G; Granucci Lesser, Joan. Clinical Social Work Practice: An Integrated Approach (p. 29). Pearson Education. Kindle Edition.

The ending phase

Ends without plan In long-term treatment, termination is not necessarily agreed on beforehand but is an outgrowth of the therapeutic process that has reached an end. (Cooper & Granucci Lesser, 2022 p. 31)