Clinical Reasoning for Difficult
Mental Health Center of Dane County 625 West Washington
Madison, Wisconsin 53703
Mental Health Center of Dane County
It is not the failure to accept limitation but the acceptance of
limitation that is at the heart of addiction. The only choice the alcoholic
feels s/he has is the decision to continue using. The problem is not a failure
to accept limitation but an inability to imagine a present and future without
the problem. Even beyond this, recovery begins with the ability to conceive a
present and a future focused on solutions. This expands the realms of
possibility, breaking the chains of limitation, transforming problems into
opportunities, and building the framework for contented sobriety. Some may call
this belief in a brighter future faith, others may call it determining one’s own
fate. Either way, the role of the therapist is to help the client construct a
future when the problem no longer exists.
Brasher, B., Campbell T.C., Moen D. (1993) Solution oriented recovery.
Journal of Systemic Therapies, 12, (3), pp. 1-15.
Watzlawick (1990)-- "The purpose of all therapy and the goal of all
schools of therapy is therapeutic change...the traditional view, according to
which the so-called patient suffers from insufficient reality adaptation and
therefore needs help in order to gain insight into the "true" nature
of things buried in his past, has become untenable." By contrast,
constructivism suggests that the painful present consequences of a specific
as-if fiction (which of course has its origin somewhere in the past) must be
replaced by the effects of a different as-if fiction, which creates a more
tolerable reality. Reality adaptation, in the sense of a better adaptation to a
supposedly "real" reality, is replaced by a better adaptation of the
fictional reality to the desired practical results." p.143.
Watzlawick (1990)--"Self fulfilling prophecies seem to turn the basic
laws of reality upside down. Imagined effect creates concrete cause; the future
(not the past) determines the present; the prophecy of the event leads to the
event of the prophecy." p.145.
Paul Watzlawick, Ph.D. 1990. Munchhausen’s Pigtail or Psychotherapy &
Reality. New York: W.W. Norton & Co.
All methods of therapy are based upon assumptions. How the therapist
thinks about change is reflected in the style of therapy chosen. Changes in ways
we explain a problem tends to result in a change in which we try to solve
TRADITIONAL THERAPY IDEAS
- Problems result from unconscious conflict.
- The past determines the present.
- People have excess pain from the past they need to deal with.
- It important to find out "why" or you are liable to repeat the
- Problems have a function for a person.
- People need to dig deeply to recover from shame.
- Many people use denial not to face the reality of a problem.
- Insight leads to change, in fact, it is necessary for change.
- If you just deal with symptoms, the problem will come back in a different
- Therapists need to listen carefully to find out the truth and what is
- Intensive problems need intensive treatment.
- People need to deal with their issues.
- Real change takes time.
ASSUMPTIONS OF A SOLUTION ORIENTED
- Preconceptions about clients hamper therapy.
- Problems are embedded in the interactional process between people more
than within the individual.
- There is no clear cause and effect in human relationships since one can
not know for sure. Symptoms are not necessarily expressions of unresolved
- Insight and awareness are not necessary for change.
- Complicated problems do not necessarily have complicated solutions.
- Change is constant and inevitable.
- A small change can lead to bigger changes.
- Every problem has an exception.
- It is easier to build on strengths and past successes than to correct past
failures and mistakes.
- People have existing and potential resources to help themselves.
- If something works, don’t fix it.
- If something is not working do something different.
THE CLINICAL MAP
Interviewing to enhance a self- perception of competence. The clinical map
is a guide. How you use it is the territory of a session. This is where the art
A) Socializing... Beginning the process of forming a relationship
with a person rather than a chemical. General conversation to help the client
feel comfortable and enhance a mutually cooperative relationship. Listen for
client’s use of language, metaphors, and way of describing herself so that you
may use this in adapting your own language to fit with the client’s. Ask about
occupation, school, hobbies, and interests. This allows you to get information
about resources, abilities, and strengths.
B) Reason for meeting... It is important to get each person’s idea
about the problem. Pay attention to the way the client describes the problem and
use language that is consistent.
C) Chemical Experience...Understanding the relationship the person
has with the chemical.
- What brings you here today?
- What would you like to happen as a result of coming here?
- What is your goal in coming here?
- What would be helpful for me to know about your chemical use?
- What would be helpful for me to know about your situation?
- What would be helpful for me to know so you know I am starting to
D) Signs of Change...Find out if there has been any change occurring
before this first session. This is where you identify and explore exceptions.
- What bothers you about your use?
- What have you tried to do about it?
- What has helped in the past?
- Are there times you could have abused but didn’t?
- What would others say about your experiences?
- On a scale of 1-10, with 1 being the worst its ever been and 10 being
where you want you be, where are you now?
- What did you do to move up to where you are now?
- Where would others say you are now?
- What do you know that they don’t know, yet?
How will you know when it is better?
E) Goal Setting...co-creating the desired solution, or keeping the
new trend going.
- How have you quit before?
- What do you do to overcome the urge?
- When you are saying "no" to drugs, what are you saying
- Which drug would be easiest to quit first, or should you quit them all at
- What will others see that lets them know you’re changing?
- Who will believe it first?
- What will you see (feel, hear) that they won’t?
- If you might give advice to someone in your situation, what might you say?
Question..."If a miracle were to happen tonight while you were
asleep and tomorrow morning you awoke to find that this problem were no longer a
part of your life, what would be different? How would know that this miracle had
taken place? How would other people be able to tell without you telling
Description..."If I had two video tapes, one of you when you
are standing up to the problem, and another when the problem is getting the best
of you, what would I notice about the one where you are in charge? What would I
notice that’s different about you in that video?" or "Let’s say that
we have two videos of you, one is in the past when the problem was really
getting in the way and the other is sometime in the near future when things are
better. What’s most noticeable in the tape of you in the future that will tell
us that things are better for you?"
Questions which assume
positive outcome..."Let’s make a leap of faith and say that
our session ends up being helpful for you, how will you know?" or "You
seem like an optimist, so let’s assume that you are able to beat this problem.
What do you imagine will be different for you?"
Questions that reinforce
taking small steps..."What will be a small sign, something
you’ll likely notice in the next week or so that will tell you that things are
better for you?" or "What will be a small sign, something you’ll
notice in the next week or so that will indicate to you there’s reason to be
Questions..."Who else may see this?" or "What will you be
doing instead?" or "What might you have to do to keep the miracle
happening?" "How will this effect your life?"
The goal here is to help the
client develop a positive emotional
orientation to the future.
FORCED CLIENT SEQUENCE
It is important for the therapist to know what they are being asked to do
and who is doing the asking. Many clients come to therapy due to being required
by outside forces. Accepting the client where s/he is helps set the stage for
the development of mutually agreed upon goals.
- Whose idea was it for you to come?
- Do you agree?
- Why do they want you here?
- Do you agree?
- What are you going to need to do to not have to come here anymore?
- What will we do with this P.O.?
- What will happen if you don’t come?
- What will convince the_ that this has been a successful experience?
- What will they see you do that make them believe you are complying?
- What will they see that lets them know a change is occurring?
- Is that important for you?
- Do you have other things you may want to talk about?
Are you here to (satisfy, change, convince) someone else or to get something
- What if this doesn’t change?
- What would you lose if you stopped?
- What are some advantages to drinking?
- What will you lose if/when you give up using?
- How will you replace that?
- Are you here to satisfy your P.O. or to get something for you?
- If you would get something for yourself, what might that be?
- How would you know when you get it?
SCREENING QUESTIONS FOR RETURNING CLIENTS
Many times clients return to treatment after previously dropping out. The
therapist can increase motivation by addressing the issues in a positive way.
Although originally developed for telephone screening, these questions can also
be used during the first interview after the client has returned to
- What is your reason for returning to treatment now?
- What do you suppose happened last time that contributed to your (dropping
out, being terminated, graduating)?
- How will you know coming here has been worthwhile?
- What will others see in you that will let them know coming here is
- Is there anything that might get in your way from this being a positive
- What have you learned while not in treatment that you can use now?
- Are there any advantages for things to continue as they are?
- What might you lose if/when you stop using?
- How will you replace that?
- Are you here to satisfy your P.O./CAU/etc./ or get something for yourself?
INTERACTIONS FOR WORKABLE GOALS
- Well-formed goals consist of actions that can be brought about by clients’
behaviors. Often they include time elements: how often, when, and how long
must it occur to be considered a real change.
- The goal is something that both client and therapist agree is possible.
- Translate vague words and phrases into action based language.
- The goal should be viewed by the client as small, concrete, achievable,
difficult, and the start of something, not the absence.
PRINCIPLES OF WORKABLE GOALS
- Should be stated in a positive form, "What will you be doing
- Should describe a process - "How will you be doing this?"
- Should include others - "What will your wife see?"
- Should make a difference - "How will doing this affect your
- Should match the client’s language - (To a carpenter:) "How will this
be a good foundation?"
PRINCIPLES OF MOTIVATIONAL INTERVIEWING
- Express empathy—the therapist seeks to communicate great respect for the
client. The therapist role is one of supportive companion and knowledgeable
consultant. Change is up to the client.
- Develop discrepancy—motivation for change occurs when people perceive a
discrepancy between where they are and where they want to be.
- Avoid arguments—attacks by the therapist usually evoke arguments by the
client. The client voices the reason for change.
- Roll with resistance—ambivalence is normal as clients consider whether to
change. Research has revealed that alcoholics no more use denial as a defense
mechanism than non-alcoholics.
- Support self-efficacy—self-efficacy is the belief that one can perform a
particular behavior or accomplish a task. Therapists need to provide hope and
STRATEGIES OF MOTIVATIONAL INTERVIEWING
- Elicit self-motivational statements.
- Use reflective listening.
- Affirm the client’s efforts
- Use reframing to allow clients to view their ideas in a new way that
causes the person to take action to change the problem.
- Summarize periodically to show you’re listening.
GROUP THERAPY MOTIVATIONAL SEQUENCE
Relative Influence Questions:
- What would be helpful for me to know about your chemical use?
- How has this had an effect on your life?
- How would (others) say this has effected your life?
- What is your longest period of clean time?
- How did you get that to occur?
- Who supports your efforts to be clean?
- What was the first thing they see that lets them know a change is
- What do they see different in you now?
- What do you see that they don’t yet.
- How will you let them know this is happening?
- How will they react differently to you that lets you know they see a
- (If previous counseling) what has been helpful for you?
- What will be different when you complete group?
- What will be some signs to you this is occurring?
- How will your life be different when this happens?
- What do you have to do to keep the change going?
Creating a New Reality:
- On a scale of 1-10 with 1 being the lowest and 10 the highest, where would
you put yourself today on Motivation, Confidence, and Degree of problem,
- How did you move from 1(the worst) to where you are now? What will be
different when you move up a little?
- What will others see that will let them know this has occurred without you
even saying anything?
- Does any of this happen now?
- What do you do to get it to happen?
People with dual diagnoses face
multiple challenges. These people have both psychiatric and chemical abuse
problems. The most devastating thing about mental illness is that it blocks the
vision of self and locks it away.
- Alcohol and other drugs are used to cope with the experience. Do not take
them away without giving something in return.
- It is important to accept the client’s experience of the voices.
- Understand the different languages used by clients to describe and account
for their experience.
- Go slow.
- Do not expect abstinence to be the initial goal of treatment.
- Use relapse as a learning opportunity.
- Deconstruct labels to allow for new possibilities.
- Show respect and caring.
- Use questions to introduce doubt—"When are you not
Phases of the Mental Illness Experience
- Loss of Control
Working with Voice Hearers
Voice hearing is not an uncommon experience. Many people experience brief
and occasional voices, particularly at times of bereavement, divorce and
separation. The religious basis of our society is derived from the experience of
- Recognize Patterns.
- Help ease anxiety.
- Help the client develop a theoretical perspective.
- Gently encourage acceptance.
- Recognize meaning.
- Look for positive aspects.
- Give skills to structure the content.
- Make effective use of medication.
- Be aware of potential dangers
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Journal of Systemic Therapies, 12 (3), pp. 1-15.
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