Monday, November 12, 2007

Techniques for Alcohol and Drug Dependent Clients

Lecture Notes
Techniques for Alcohol and Drug Dependent Clients
Instructor - Jeff Garrett Ph.D.


Many Intensive Outpatient Treatment Programs for alcohol and drug dependent clients use 12 Step Recovery and encourage clients to participate in AA.

Encourage Participation in AA

The 12 Steps

1. We admitted we were powerless over alcohol - that our lives had become unmanageable.
2. Came to believe that a power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong, promptly admitted it.
11. Sought though prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

If time permits, you may also ask one of the clients to read the 12 traditions of AA and process them in group.

The 12 Traditions

1. Our common welfare should come first; personal recovery depends upon A.A. unity.
2. For our group purpose there is but one ultimate authority - a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
3. The only requirement for A.A. membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or A.A. as a whole.
5. Each group has but one primary purpose-to carry its message to the alcoholic who still suffers.
6. An A.A. group ought never endorse, finance or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property and prestige divert us from our primary purpose.
7. Every A.A. group ought to be fully self-supporting, declining outside contributions.
8. Alcoholics Anonymous should remain forever nonprofessional, but our service centers may employ special workers.
9. A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.
11. Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio and films.
12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

Discussion

Discuss how these steps (and traditions) can be incorporated into group and individual counseling.

Possible Discussion Questions regarding the 12 and 12
• Why are these steps read at the beginning of each AA meeting?
• What role do the 12 steps play in recovery?
• Why do you have to work each step one at a time?
• What is a sponsor’s role in relation to the 12 steps?
• How do you get a sponsor? (Role play asking someone to be a sponsor).
• How do you feel about asking someone to sponsor you?
• What should you expect from your sponsor?
• Why is it important to read the Big Book?
• Why is it important to attend meetings?
• What should you expect when you go to meetings?

Discuss the Possible Benefits of Serenity (Peace)

• Steps 1 – 3 (Peace with God)
• Steps 4 – 7 (Peace with Self)
• Steps 8 – 10 (Peace with Self)
• Steps 11 – 12 (Keeping the Peace)

Discussion Questions Serenity and Peace
• How has alcohol and drug abuse interfered with your life?
• How does the serenity prayer relate to peace?
• How does a lack of serenity relate to your motivation level?

Identify Your “Triggers”

What people are paired with your addiction? __________

What places are paired with your addiction? __________

What things are paired with your addiction? __________

What feelings are paired with your addiction? __________

What times are paired with your addiction? __________


Identify Your Triggers

Instructions for Counselor: This worksheet, (adapted from Carroll, 1998) will help you identify your triggers. Please reflect each major area (Social, environmental, mental, emotional, and spiritual) as you record your answers in writing. Then share your written responses with the group.

Social Triggers:

Do you typically use alcohol or other drugs when you are alone or with other people? __________

Environmental Triggers:

Where do you typically use alcohol or other drugs? What situations or circumstances trigger your use? __________


Mental Triggers:

What thoughts typically trigger your use of alcohol or other drugs?
__________


Emotional Triggers:

What feelings typically trigger your use of alcohol or other drugs? __________


Spiritual Triggers:

How would you describe your spiritual life when you are triggered to use? __________

Other relevant questions:
What is your pattern of use (weekends only, every day, binge use)?
What has happened to (or within) you before the most recent episodes of abuse?
How would you describe its effects on you before, during and after you use?

Replacing Addictive Behaviors with Healthy Ones

Instructions for Counselor: Recovery involves replacing addictive behaviors for healthy ones. Below is a list of healthy behaviors which can be used to replace unhealthy ones. Please identify which behaviors you plan to use by placing a “check” in the corresponding box.

Going to AA meetings.
Doing service work.
Reading the Big Book.
Working the Steps.
Getting a sponsor.
Calling your sponsor.
Participating in group.
Exercise.
Going to church.
Practicing good hygiene.
Socializing with friends who support your recovery.
Going to work.
Praying.
Gardening or yard work.
Cleaning house.
Paying bills.
Taking care of your children.
Attending community activities.
Keeping appointments.
Continue counseling.

Other healthy behaviors? __________

Coping with Craving

Instructions for counselor: Building on the work of Carroll (1998), this section contains CBT concepts related to craving. The counselor should present the material in a conversational manner. Invite group members to participate. Ask questions, invite comments and check understanding. Let it be a collaborative dialogue. Make it simple, concrete and relevant to the group members.

Below I have listed and explained how therapists can present the material on craving. The presentation is merely a guide or example. It is not necessary to present the concepts and techniques as I do. Learn the basic concepts and techniques, then present it in a way that is consistent with your own style.

1. How to introduce the topic of craving

The therapist may introduce the topic of craving with this simple explanation: “Craving is a common problem for most people in recovery. You may experience episodes of intense craving for alcohol or drugs. The experience can be both mystifying and disturbing if it is not understood and manage effectively.

The goals of this session are:
• To understand craving as you experience it.
• To understand that craving is a normal and time-limited experience.
• To learn various coping strategies to help you effectively deal with craving.

2. Questions for group members

After the brief introduction the therapist may begin by asking questions like:
• Describe your own experience of craving?
• When does it typically happen?
• How long does it last?
• What triggers it?
• What are the similarities and differences in your responses?

Try to identify similarities and differences among group members. Group members may identify common triggers like being around people with who use alcohol or drugs, having money or getting paid, certain social situations, and certain mood states, such as anxiety, depression, or joy. They also identify triggers that are unique to themselves. Triggers for craving can be highly idiosyncratic, thus identification of cues should take place in an ongoing way throughout treatment.

3. Review Pavlov

Review the material on conditioned cues by paraphrasing Pavlov’s dogs. Use concrete and relevant examples that help clients understand and relate the concept of craving to their own experience. You may asked questions like: “Can you identify the personal “bells” that trigger craving alcohol or drugs? Such questions help clients demystify the experience of craving and enable them to identify and tolerate conditioned craving when it occurs.

4. The therapist may ask questions like:

What is craving like for you?
What is the feeling like?
Do you experience any physical sensations?
Where in your body do you experience these physical sensations?
How strong is it?
Does it move or change?
Where else does it occur?
How long does it last?
How bothered are you by craving?
How do you try to cope with it?

5. Review the Identifying your Triggers Worksheet

As you review the Identifying Triggers Worksheet focus on identifying the craving and cues that have been most problematic in recent weeks. Encourage clients to monitor their craving so that they can identify new, more subtle triggers as they arise.

6. Learning how to Avoiding Cues

Help clients understand that the general strategy of "recognizing, avoiding, and coping" is particularly applicable to craving. After triggers have been recognized it is important for clients to avoid them. This may include breaking ties or reducing contact with individuals who use alcohol or drugs, getting rid of paraphernalia, staying out of bars or other places where alcohol or drugs are used, or no longer carrying more money than needed.

7. Learning how to Coping With Craving

The therapist may present the following strategies for coping with craving. Present each coping strategy with questions for discussion.

• Distraction – What activities can you use to distract yourself?
• Talking about craving – Who can you call? What would you say?
• Recalling the negative consequences of substance abuse – Can you recall or remember the negative consequences of substance abuse? Can you mentally rehearse these memories during episodes of craving?
• Using self-talk – What are some self-coping statements you can use during episodes of craving? Can you list five self-coping statements you could use to help you cope with craving?

8. Demonstrate progressive relaxation

Therapists should explain how progressive relaxation can be used as an effective way to cope with craving.

9. Demonstrate Breathing Exercises

To introduce this coping strategy the therapist may say something like: As you know, the physical sensation of craving can create stress and tension in your body. It’s important to learn how to relax your body during episodes of craving. Another coping skill you can use is breathing exercises. Then give each client the worksheet on the page that follows.

Instructions for Counselor: Learning to be assertive in refusing offers for drugs and alcohol is an essential part of recovery. This session focuses on teaching clients steps to reduce availability and enhance refusal skills. The two worksheets below can be used. The first is the "Managing Availability Worksheet" and the second is a "Refusal Skills Worksheet" (Kadden, et al, 1992).

Managing Availability Worksheet
(Kadden et al., 1992)
List sources of alcohol and drugs here and what you'll do to reduce availability (for example, people who might offer you alcohol or other drugs, places you might get it). If clients prefer, they can use imaginary names for real ones.

Source ________
Steps I'll take to reduce availability ____________

Source ________
Steps I'll take to reduce availability ____________

Source ________
Steps I'll take to reduce availability ____________


Refusal Skills Worksheet

Instructions for Counselor: Learning and practicing refusal skills is essential to recovery. Below are some basic tips for responding to offers of alcohol and other drugs (from Monti et al, 1989).

Tips for responding to offers of alcohol or other drugs (Monti et al, 1989):
• Say no first.
• Make direct eye contact.
• Ask the person to stop offering it.
• Don't be afraid to set limits.
• Don't leave the door open to future offers (e.g., not today).
(Chart from Monti, et al, 1989 as in Carroll, 1998)

People who might offer me alcohol/drugs
A friend I used to use with:
A coworker:
At a party:

What I'll say to them
_____________
_____________
_____________

Anger and it’s Negative Consequences

Instructions: The counselor initiates the discussion by defining anger and exploring its consequences. The explanation below may be used.

Anger is an emotion state that varies in intensity from mild irritation to intense fury and rage. Everybody gets angry. Anger is not bad. It’s healthy and appropriate to express anger in constructive ways. But we want to avoid inappropriate expressions of anger that are destructive. Anger management is an important skill that you can learn.

Possible Discussion Questions

• How does anger relate to resentment?
• How is resentment related to sobriety?
• What triggers your anger?
• How do you express anger?
• How do drugs and alcohol affect your anger?
• Describe how your body responds when you get angry?
• Describe your thoughts during angry spells – racing? locked?
• Describe your emotions during anger? How intense?
• Describe your behavior – aggressive? passive? withdrawn?
• Describe a situation where you expressed your anger appropriately.
• Share a situation where you expressed your anger inappropriately.
• How to you cope with anger? What works for you?
• What are some negative consequences to anger?

How could anger negatively affect your …
o Recovery?
o Relationships?
o Mental health?
o Spirituality?
o Career?

Anger Management

Instructions: Once the concept of anger and its negative consequences has been process by the group, the counselor should identify effective methods for managing anger. The counselor may begin this part of the discussion by saying…

There are a several effective ways to manage anger. In fact, everyone has their own developed some skills for calming themselves down and expressing anger in appropriate ways. I want you to share some ways you manage your own anger.

Group members will share as many anger management strategies as they can think of while the counselor guides the group, enhancing dialogue between clients. After clients have exhausted their methods of dealing with anger the counselor may add skills like …

Going to a meeting.
Working Steps 4 and 5.
Relating Steps 6, 7, 8, and 9 to anger and resentment.
Saying the serenity prayer.
Using AA slogans.
Doing service work.
Talking to your counselor.
Staying busy.
Thought stopping.
Talking to your sponsor.
Identifying irrational beliefs.
Owning your anger.
Allowing angry emotions to be expressed in proportion to the offense.
Accepting responsibility for creating your own mood.
Redirecting.
Reframing.
Refocusing.
Labeling cognitive distortions.
Using self-coping statements.
Practicing deep breathing.
Positive imaging.
Listening to music.
Reading.
Watching a movie.
Exercise.
Self-soothing – sensations.
Socratic questioning.
Humor.
Time-out - Counting to 10 (or 1,000).
Using guidelines for conflict resolution.
Forgiving – releasing.
Using the ABC’s of Emotion.

Developing an All Purpose Coping Plan / Relapse Prevention

Instructions for Counselor: The objective of this final session is threefold: 1) To help clients develop an all purpose coping plan; 2) To present and discuss symptoms that may lead to relapse; 3) To review the 12 steps of recovery. In addition to these three session goals the counselor may add other pertinent AA material and discuss the importance of 12 step programs in life-long recovery.

Developing an All Purpose Coping Plan (Adapted from Carroll, 1998).

The counselor should facilitate the group to ensure each client completes coping plan as follows.

If I run into a high-risk situation:

1. I will leave or change the situation.
Safe places I can go: _______________

2. I will put off the decision to use for 15 minutes. I'll remember that my cravings usually go away in ______ minutes and I've dealt with cravings successfully in the past.

3. I'll distract myself with something I like to do.
Good distracters: _______________

4. I'll call my list of emergency numbers:
Name:_______________Phone #: _______________
Name:_______________Phone #: _______________
Name:_______________Phone #: _______________


5. I'll remind myself of my successes to this point: _______________

6. I'll challenge my thoughts and beliefs by: _______________


Relapse Prevention

Instructions: Helping clients to identify and avoid high risk situations is an important goal. In addition, the counselor will help clients become aware of symptoms leading to relapse using the list below.

Not attending meetings.

Not having or working with a sponsor.

Not working the steps.

Not mediating.

Not praying.

Not reading AA material.

Not serving.

Exhaustion.

Dishonesty.

Impatience.

Anger

Conflict in relationships.

Depression.

Frustration.

Self-pity.

Cockiness.

Complacency.

Expecting too much from others.

Entitlement.

The use of mood-altering chemicals.

Chapter 6 Expressive Techniques

Lecture Notes
Chapter 6 Expressive Techniques
Counseling Techniques – Rosemary Thompson
Instructor - Jeff Garrett Ph.D.



ART THERAPY, DANCE/MOVEMENT THERAPY, DRAMA THERAPY, MUSIC THERAPY, PSYCHODRAMA, AND WRITING AS THERAPY

The expressive or creative arts therapies include art therapy, dance therapy, drama therapy, music therapy, psychodrama, phototherapy, writing as therapy, and poetry therapy.

ART THERAPY

Art therapy is a human service profession that uses art media, images, the creative process, and patient/client responses to their created products as tangible products that symbolize the client's inner world-reflections of an individual's development, abilities, personality, interests, concerns, and conflicts.

Technique: Melting Mirror
Counseling Intention To identify early memories that made deep impressions.

Description Reach back to childhood imaginatively. As you look at yourself in a mirror, it seems to melt and the image wavers. When it settles it reveals you as a child in a room in your house. Imagine the room and a conversation between you and your child-self. What does the child say to you? What do you reply? Paint the situation and see if there are any messages in it for you now (Liebman, 1986. p. 145).

Technique: Life Priorities Collage

Counseling Intention To reassess priorities.

Description On a large piece of paper, paint three horizontal bands of color to represent far, middle, and near distances. Then cut out or draw pictures to represent different aspects of your work, family, and social life. Glue or tape these pictures on the appropriate band of color. When you have finished, reflect on the results and move pictures around until the whole feels comfortable (Liebman, 1986, p. 144).

DANCE/MOVEMENT THERAPY
Dance therapy, also referred to as movement therapy, is the psychotherapeutic use of movement as a process to integrate the emotional, cognitive, social, and physical processes of the client. Dance is the most fundamental of the expressive arts, involving direct expression through physical movement of the body. Based on the assumption that body and mind are interrelated, dance therapy is defined as “the psychotherapeutic use of movement as a process which furthers the emotional, cognitive and physical integration of the individual.” Dance therapy effects changes in feelings, cognition, physical functioning, behavior, and attitude, helping clients to:
• Reduce stress.
• Tap emotions and sensations that people ordinarily avoid.
• Build self-confidence.
• Define boundaries personally and somatically without having to do so in relation to others.
• Be assertive or intimate without losing sense of self.
• Experience and honor the present no matter what stage of healing.
• Express themselves authentically through dance, movement, music, writing, and art making.

In addition to those with severe emotional disorders, people of all ages and medical conditions receive dance/movement therapy. Examples of these are individuals with eating disorders, adult survivors of violence, sexually and physically abused children, dysfunctional families, the homeless, autistic children, the frail elderly, and substance abusers. An emerging area of specialization is using dance/ movement therapy in disease prevention and health promotion programs and with those who have chronic medical conditions. Many innovative programs provide dance/movement therapy for people with cardiovascular disease, hypertension, chronic pain, or breast cancer.

PHOTOTHERAPY
Phototherapy is an interactive system of techniques that makes use of people's personal snapshots and family albums to access feelings and memories not easily available in more directive approaches in counseling and psychotherapy. Clients interacting with the therapist about their own personal and family photos begin discussing what their own personally meaningful snapshots are about. Many associated thoughts and feelings will spontaneously emerge and thus be more available for conscious and cognitive exploration and integration.

DRAMA THERAPY
Drama therapy is the systematic and intentional use of drama/theater processes, products, and associations to achieve the therapeutic goals of symptom relief, emotional and physical integration, and personal growth. Drama therapy is an active approach that helps the client tell his or her story to solve a problem, achieve a catharsis, extend the depth and breadth of inner experience, understand the meaning of images, and strengthen the ability to observe interpersonal roles and intrapersonal feelings. The balanced verbal and nonverbal components of drama therapy, with its language of metaphor, allow clients to work productively within a therapeutic alliance.

Participants can expand their repertoire of dramatic roles to find that their own life roles have been strengthened. Behavior change, skill-building, emotional and physical integration, and personal growth can be achieved through drama therapy in prevention, intervention, and treatment settings.

PSYCHODRAMA

As conceived and developed by Moreno (1975), psychodrama employs guided dramatic action to examine problems or issues raised by an individual client (psychodrama) or by a group (sociodrama). Psychodrama is more of a systematic therapeutic procedure than a counseling technique.

Using experiential methods such as sociometry, role theory, and group dynamics, psychodrama serves to promote insight, personal growth, and the integration of cognitive, affective, and behavioral domains. It clarifies issues, increases physical and emotional well-being, enhances learning, and develops new skills by concentrating on the private components of roles. The therapeutic “team” in psychodrama has five elements: the director, the protagonist, the auxiliaries, the group, and the action space.

The therapeutic “team” in psychodrama has five elements

• Protagonist: Person(s) selected to “represent the theme” of group in the drama.
• Auxiliary egos: Group members who assume the roles of significant others in the drama.
• Audience: Group members who witness the drama and represent the world at large.
• Stage: The physical space in which the drama is conducted.
• Director: The trained psychodramatist who guides participants through each phase of the session.

Three Stages (Structural Components) of Group Interaction
In a classically structured psychodrama session, there are three distinct stages (structural components) of group interaction:

1.Warm-up: The group theme is identified and a protagonist is selected. The primary objective is to increase the level of readiness.

2.Action: The problem is dramatized and the protagonist explores new methods of resolving it. This includes three fluid connected segments:
A. The first segment outlines the role playing of “the complaint”-the present difficulty.
B. The second segment is “explorations” and “clarifications, ” which include a number of scenes to investigate the difficulty.
C. The last segment is “rehearsing and searching for alternatives” by presenting an enactment of solutions for the conflicts. “It is the shift from one scene to another that produces the therapeutic effect not excessive exploration of the scene” (Kipper, 1992). The action stage typi cally lasts for 60% of the session.

3. Sharing: Group members are invited to express their connection with the protagonist's work. The auxiliaries and group members share their common or similar experiences with the protagonist so that he or she is not left feeling alone with the difficulty (Kipper, 1992).

Psychodrama affords participants a safe, supportive environment in which to practice new and more effective roles and behaviors. A classic psychodrama session follows a unique structure. Following a contractual agreement between the protagonist and director, the presenting scenes or issues-usually recent events or here-and-now feelings-are enacted. Following scenes move closer toward origins or core issues of the presenting problem. From insights gained, it then becomes possible to return to the presenting issues; role training and a review of the contract may precede sharing and closure.

Psychodrama is a therapeutic approach that uses action methods, sociometry, role playing, and group dynamics to facilitate constructive change in the lives of psychodrama participants. By closely approximating life situations in a structured therapeutic environment, the client can re-create and enact scenes in a way that promotes awareness, insight, and an opportunity to practice new life skills. In psychodrama, the client (or protagonist) focuses on a specific situation to be enacted. Other members of the group act as auxiliaries, supporting the protagonist's work by taking the parts or roles of significant others in the scene. This encourages the group as a whole to partake in the therapeutic power of the drama. Because the therapist helps to recreate scenes that might otherwise not be possible in real life, the psychodrama then becomes an opportunity to practice new and more appropriate behaviors, and evaluate their effectiveness within the supportive atmosphere of the group. The dimension of action is present, so psychodrama is often empowering in a way that exceeds the more traditional verbal therapies (Blatner, 1988; Leveton, 1992).There are two additional branches of psychodrama: sociometry and sociodrama. Sociometry, the study and measure of social choices within a group, helps to bring to the surface patterns of acceptance or rejection and fosters increased group cohesion. This surfacing of value systems and norms of a group allows for restructuring that will lower conflicts and foster relationships. Sociometry has been used in schools and corporations as well as within the mental health field. Sociometry had several goals (Treadwell, Kumar, & Collins, 1997; Treadwell, Kumar, Stein, & Prosnick, 1997, 1998):

Goals of Sociometry
• Facilitate constructive change in individuals and groups.
• Increase awareness, empathy, and reciprocity in social interactions.
• Explore social choice patterns and reduce conflicts.
• Clarify roles, interpersonal relations, and values.
• Reveal overt and covert group dynamics.
• Increase group cohesion and productivity.

Sociodrama is a form of psychodrama that addresses the group's perceptions of social issues. Rather than being the drama of a single protagonist, this process allows the group as a whole to safely explore its perceptions. Members might address problems such as teenage pregnancy or drug abuse, and together arrive at understanding and innovative responses to these difficult issues.

Psychodrama seeks to use a person's creativity and spontaneity to reach his or her highest human potential. With its focus on the social network in which an individual lives, it promotes mutual support and understanding. Moreno (1975) explained psychodrama's goal as making it possible for every person to take part in creating the structure of the universe, which “cannot have less an objective than the whole of mankind.”

Technique: Psychodrama Techniques

Counseling Intention Improvising an encounter in the here-and-now to circumvent habitual defensive patterns.

Description Physical enactment provides an immediacy and vividness that leads to a more emotionally anchored “action insight.”

The following represent typical techniques used in psychodrama:

Aside: The actor speaks to the audience while indicating through gesture that the others in the scene cannot hear, thus bringing ideas and feelings at the edge of awareness out into the open.

Soliloquy and speaking behind the back: The client says things regarding another person as if that other person were not present; this is particularly helpful in promoting disclosure in family therapy (Blatner, 1988, 2000).

Role reversal: The therapist suggests that the client imagine what it is like to be in the role of a significant other, and then helps the client foster a more mature level of understanding and empathy.

Active empathy: Working through the client's self-system, the therapist expresses what might be the client's inner thoughts or feelings. Then the therapist checks out the performance and invites the client to correct it so that the therapist can be more understanding of the client's point of view.

MUSIC THERAPY

Music therapy unites the fields of music and therapy to provide a creative treatment and medium. It combines music modalities with humanistic, psychodynamic, behavioral, and biomedical approaches to help clients attain therapeutic goals that are usually mental, physical, emotional, social, and/or spiritual in nature. Many studies have been done on the beneficial physiological changes promoted by music on mood, blood pressure, breathing, pulse rate, respiration, cardiac output, heart rate, muscle tension, pain, and relaxation. Music therapeutically addresses physical, psychological, cognitive, behavioral, and/or social functioning.

Music therapists work in a wide variety of settings with the emotionally disturbed, the learning disabled, the mentally handicapped, and the physically challenged. They also work with clients with psychiatric disorders, alcohol and drug problems, and neurological disorders, and those who are terminally ill.

Music therapists offer services in skilled and intermediate care facilities, adult foster care homes, rehabilitation hospitals, residential care facilities, hospitals, adult day care centers, retirement facilities, senior centers, hospices, senior evaluation programs, psychiatric treatment centers, and other facilities. Music therapists also work for agencies that provide in-home care.

Music therapy is also used with healthy individuals to assist in stress reduction, childbirth, and biofeedback. Advanced opportunities in education and private practice are possible.

Music therapists have been successful in a wide variety of settings with the emotionally disturbed, the learning disabled, the mentally handicapped, and the physically challenged. They also work with clients with psychiatric disorders, alcohol and drug problems, neurological disorders, and those who are terminally ill. Music therapy is also used with healthy individuals to assist in stress reduction, childbirth, and biofeedback (Bartlett, Kaufman & Smeltekop, 1993; Boldt, 1996).

Poetry Therapy and Bibliotherapy

Poetry therapy and bibliotherapy are terms used synonymously to describe the intentional use of poetry and other forms of literature for healing and personal growth. Bibliotherapy has a broad range of applications with people of all ages and is used for health and maintenance, as well as with individuals undergoing treatment for such conditions as heart disease, cancer, and addiction. Bibliotherapy has been effective with veterans of the armed services, substance abusers, adolescents, the learning disabled, dysfunctional families, prisoners in rehabilitation, the elderly, the physically challenged, and survivors of violence, abuse, and incest. The literature and case studies provide evidence that poetry therapy is an effective and powerful tool with many different populations.

The Goals of Poetry Therapy

• To develop accuracy and understanding in perceiving self and others.
• To develop creativity, self-expression, and greater self-esteem.
• To strengthen interpersonal skills and communication skills.
• To ventilate overpowering emotions and release tension.
• To find new meaning through new ideas, insights, and information.
• To promote change and increase coping skills and adaptive functions.

Technique: Book of Self

Counseling Intention To get in touch with experienced grief, loss, loneliness, success, triumph, and stability.

Description The “Book of Self” begins with a brief biological sketch limited to one to three pages. Next, include some photographs of the person at various stages of life. Awards, certificates, and other forms of appreciation and recognition are collected for the next section. Hobbies and recreation activities can be included. A summary statement or a collage of self as the person is today forms the final part (Brown, 1996).

Technique: Creative Writing

Counseling Intention To encourage clients to project inner thoughts and feelings through writing.

Description Creative writing is another written format through which clients can clarify projections and in which problems are explored and therapeutic dialogue interchanged. Troubling issues and concerns can have a therapeutic outlet, especially among adolescents (Dehouske, 1979).

Technique: Structured Writing and Therapeutic Homework

Counseling Intention To encourage clients to keep records of their ideas and questions so that counseling time can become more structured.

Description Therapeutic homework originated from behavioral and cognitive models, which traditionally have favored briefer forms of therapy. This method tends to reduce the need for repeated counseling and is applicable to both individuals and small groups. Clients who seek help for personal or academic problems may keep structured notebooks about their concerns and receive highly organized answers and instructions from counselors. They may complete inventory questionnaires, writing contracts, or document behavior modification procedures systematically (Corbishley & Yost, 1985; Klier, Fein, & Genero, 1984).

Technique: Fix Your Attention on Each of Your Five Senses

Counseling Intention To be in the moment, the here-and-now (Hughes, 1991, pp. 70-71).

Description Think for a moment about each of the five senses and the organs primarily responsible for that sense.

Eyes-sight: “What do you see?”
Ears-hearing: “What do you hear?”
Nose-smell: “What do you smell?”
Mouth-taste: “What do you taste?”
Skin-touch: “What do you feel?”

• Write three to five separate sentences for each of the five senses.
• Write the sentences in the present tense, as if the experience is happening now.
• Locate the experience in time and space.
• Use comparisons if they strike you.

Chapter 15 - Eclectic Techniques for Use with Family Systems

Lecture Notes
Chapter 15 - Eclectic Techniques for Use with Family Systems
Counseling Techniques – Rosemary Thompson
Instructor - Jeff Garrett Ph.D.


Marriage and family therapists work with:
• Families facing depression, major mental illness, or emotional disorders.
• Custody mediation for families facing divorce.
• The alcohol or drug abuser and his or her family.
• Persons with chronic illness and disability and their families.
• Crime victims struggling to reclaim their lives, and their family members.
• Patients and the family members who care for them.
• HlV-positive individuals, people living with AIDS, and their family members.
• Veterans, firemen, police officers, emergency medical technicians seeking counseling following a devastating traumatic event.
• Military personnel and their family members.
• Families facing possible loss of their children to out-of-home placement.
• The homeless and homeless mentally ill.
• Abuse victims and perpetrators.
• Immigrants adjusting to a new life in the United States.
• Adolescents at risk for incarceration (and their families).
• Families in the foster care system.
• Providing treatment alternatives to prison.

Family Systems Theory
The systems theoretical framework views the family as a self-regulating system joined together by unspoken rules whose purpose is to maintain itself. The focus of treatment becomes the family system, not the problem or symptomatic family member. A number of theoretical models have evolved with their respective counseling techniques. Many therapists, however, are eclectic and use the model and technique most appropriate for a particular family and treatment setting.

Eleven Theoretical Models of Family Systems Theory

1. Psychodynamic - an object relations approach to family therapy pioneered by Ackerman (1958) and originally described by Fairbairn (1967) and Klein (1959) and applied to marital relationships by Dicks (1967). It views dysfunction as the result of inappropriate behavioral attempts to work out issues of the past. Since the 1980s there has been a resurgence of interest in psychodynamics among family therapists, spurred on by object relations theory and self-psychology integrating depth psychology and systems theory (Kirschner & Kirschner, 1986; Nichols, 1987; Sander, 1989).

2. Family Systems Therapy - focuses on the importance of differentiation, relationships between generations, transgenerational dysfunctions (such as alcoholism), and triangulation (Bowen, 1978; Kerr, 1980), with a focus on multigenerational family systems, i.e., how interlocking triangles connect one generation to the next. The idea of intergenerational conditions has been very influential in the counseling field. According to Bowen (1971, 1974, 1975), the major problem in families is emotional fusion. The fundamental solution is differentiation. The triangle is the primary focus of analysis in both principle and practice. Like Freud, Bowen believed the important impact of early family relationships. The primary relationship between the self and parents is described as a triangle and has major implications for life.

3. Experiential Family Therapy - Designed to change family members, families are treated as groups of individuals more than systems. Interpersonal change and growth is emphasized more than problem solving. Therapists seek intense emotional awareness, expressive techniques, and interventions that take the form of self-disclosure, teasing, sarcasm, humor, personal confrontation, paradoxical intention, and modeling (Duhl, 1983; Duhl & Duhl, 1981).

4. Communications - describes pathology manifested in dysfunctional communication patterns (Bateson, 1972; Jackson & Weakland, 1961; Satir, 1967; Satir & Baldwin, 1983). Treatment focuses on changing interpersonal interaction patterns to promote growth and to increase self-esteem, conflict resolution, and new adaptive responses to dysfunctional communication.

5. Structural Family Therapy - views family dysfunction as a consequence of family structure (Haley, 1976, 1984; Minuchin, 1974; Taylor, 1984). Wisdom and insight come only after structural change. Structural family theory has become one of the most widely used conceptual models in the field. The fundamental tenet of this approach is that every family has a structure that is revealed only when the family is in action. The basic structural concepts are boundaries, subsystems, alignments, and complementarity. Therapists take into account the individual family and social context, providing a clear organizing framework for understanding and healing families.

6. Systems - emphasizes the influence of networks of relationships upon individuals. Relationships can be understood as any unit of interaction or communication between individuals.

7. Strategic Intervention - a brief treatment model of therapeutic change designed by the Akerman Institute, Haley (1976, 1984), and Selvini-Palazzoli (1978). Strategic intervention is aimed at changing the powerful family rules in families that are particularly resistant to change.

8. Transactional Analysis - created by Eric Berne (1961, 1964), deals with aspects of the personality that other techniques may exclude: the behavioral, the interpersonal, and the intrapsychic. It is a contractual form of therapy that focuses on ego states of parent, adult, child, and aspects of rescripting for redecision and change.

9. Multiple-Family Group Therapy - proposed by Bahatti, Janakiramariah, and Channabasvanna (1982), employs multiple family group therapy as a means for establishing support and help to a family. The family benefits through an extended family living experience. Mutual support and belongingness are common goals; the entire group serves as a resource for problem solving, generating alternatives, and developing action plans for change.

10. Cognitive-Behavioral Family Therapy - is used primarily to teach parents how to apply learning theory to control their children; to help parents substitute positive for aversive control; and to diminish anxiety in couples with sexual problems. Treatment is usually time limited and symptom focused, based on social learning theory. Behaviorists have developed a wealth of reliable and valid diagnostic and assessment methods and applied them to evaluation, treatment planning, and monitoring progress and outcomes.

11. Narrative Therapy - is organized around two simple metaphors: a client's personal narrative and social construction (i.e., challenging the notion of an objective basis for knowledge shaped by culturally shared assumptions). By challenging rigid and pessimistic versions of events, therapists make room for flexibility, optimism, and hope. The strategies of narrative therapy fall into three stages: (1) recasting the problem as a misfortune by focusing on the effects rather than the causes; (2) finding exceptions or partial triumphs over the misfortune and instances of successful experiences; and (3) some kind of public ritual to reinforce new and preferred interpretations (Brunner, 1991; Freedman & Combs, 1996; White & Epston, 1990; Zimmerman & Dickerson, 1996).


TECHNIQUES

Technique: Constructing a Compromise That Both Parties Can Live With

Counseling Intention To get both partners to yield a little and find their common ground so that they can arrive at a compromised position on an issue. These strategies work with solvable problems (Gottman, 1999, p. 233).

Description In this exercise, spouses work together to try to develop a common way of thinking about an issue and start to construct a compromise that they can both live with. They should ask their partner these questions:
1. How can we understand this issue? Can we develop a compromised view?
2. What are common feelings or the most important feelings here?
3. What common goals do we have?
4. What methods can we agree upon for accomplishing these goals?

Technique: Sharing Meaning in Family Rituals

Counseling Intention To build or strengthen shared meaning around rituals (Gottman, 1999, p. 261).

Description Couples explore the following questions to develop their own family rituals:
1. How do we eat dinner? What is the meaning of dinner time? How was dinner time done in each of our families growing up?
2. How should we part at the beginning of each day? What was it like in our families growing up? How should our reunions be?
3. How should bedtime be? What was it like in our families growing up? How do we want this time to be?
4. What is the meaning of weekends? What was it like in our families growing up? What should they be like?

Questions can continue regarding vacations, holidays, sickness, time alone, work, children, and so on.

Technique: Building Shared Meaning in Family Roles

Counseling Intention To build shared meaning around roles (Gottman, 1999, p. 262).

Description Couples explore the following questions to develop their own family roles:
1. How do you feel about your role as husband or wife? What does that role mean to you? How did your father or mother view this role? How are you similar or different? How would you like to change this role?
2. How do you feel about your role as a father or mother? What does it mean to you? How did your father or mother view this role? How are they similar or different? How would you like to change this role?

Questions continue focusing on issues such as role as son or daughter, as work and career, as friend to others, in the community, and how to achieve balance among all of these responsibilities.

Technique: Counseling Techniques for Dysfunctional families

Counseling Intention To help family members demonstrate how they normally deal with situations.

Description Anderson (1988) capsulated several techniques that can be useful in assessing how families work together, their developmental stage, and their real versus presenting problem.

Sequencing. Ask questions such as who does what, when? When the kids are fighting, what is the mother or father doing?

Hypothetical questions. Who would be most likely to stay home if a child became ill? Which child can you visualize living at home as an adult?

Scaling reports. On a scale of most to least, compare one another in terms of anger, power, neediness, and happiness.

Family map. Organize information about the generational development of the family that reveals the transmission of family rules, roles, and myths (Bowen, 1978).

Tracking. How does the family deal with a problem? “What was it like for you when X?” rather than “How did you feel when X?” Such questions help keep the focus on the family rather than on the individual.

Sculpting. Create a still picture of the family that symbolizes relationships by having members position one another physically. This technique can be used to cut through defenses and helps nonverbal members express themselves.

Paradoxical intervention. Instruct the family to do something unexpected; observe how the family changes by rebellion or noncompliance. This is often most appropriate with highly resistant or rigid families.

Technique: Airing Grievances Constructively

Counseling Intention To provide a constructive way to build a new relationship.

Description The following guidelines provided by Bach and Wyden (1968) are designed to provide a constructive way of rebuilding relationships between couples. It can be adapted for any two people with conflict or resentment toward each other. Make an appointment to confront each other. Many conflicts and accompanying dialogue are unproductive because only one individual is ready to confront the issues and the other may refuse to fight. Designating a time without distractions provides a more equitable advantage.

• Take turns expressing resentments. Let one person talk for five minutes without interruption. Reciprocate the process.
• When all issues are presented, have your partner repeat the concerns as you outlined them. Check for understanding. Reciprocate the process.
• Clearly state your expectations of each other-the behavior you will not resent.
• Determine together if your expectations are realistic, negotiable, or both. Then proceed with a mutually satisfactory agreement about the future. Be as specific as possible about compromises and expectations.

Technique: Exercises to Open Communication

Counseling Intention Satir (1967) provided a strategy for helping couples reach a deeper level of communication and understanding.

Description Instruct couples to do the following:
• Stand back to back and talk to each other. This simulates what frequently occurs when one partner wants to talk finances or schedules and the other is reading the newspaper, fixing dinner, or otherwise preoccupied.
• Stand face to face, and look at each other without talking. What do you think your partner is thinking and feeling? When discussing, check for the accuracy of your perception.
• Now eyeball each other, and communicate without talking. See how much more communication gets through.
• Close your eyes and communicate without talking.
• Eyeball each other and talk without touching.
• Use all forms of communication (talk, touch, look at each other).

Most couples find it difficult to argue with each other without looking away or withdrawing physically. Touch and eye contact creates more intimacy.

Technique: The Total Truth Exercise

Counseling Intention To acknowledge pent-up feelings (Marston, 1994).

Description Releasing pent-up feelings can help gain control of emotions. The total truth technique helps free excess emotional baggage in conflictual relationships. Write a letter to the person with whom you have a conflict to express the full range of your emotions, starting with anger and ending with forgiveness. If you proceed to the section on forgiveness, but still have feelings of anger or sadness, go back to the angry part of your letter and keep writing until you feel free of that particular emotion.

Anger and Resentment
I'm angry that…
I hate it when…
I'm fed up with…
I resent it when…
I can't stand it when…

Hurt
I feel hurt when…
I feel rejected when…
I feel sad when…
I feel jealous about…
I feel disappointed about…

Fear
I feel scared when you…
I feel scared that you don't…
I'm afraid that…
I feel insecure about…
I'm afraid that I…

Remorse and Regret
I'm sorry that…
I regret that I…
Please forgive me for…
I didn't mean to…
I feel sad that…

Wants
All I ever wanted was…
I want you to…
I wish that…
I deserve…
I want us to…
What I really want is…

Love and Forgiveness
I forgive you for…and I forgive myself for…
What I love most about you is…
I understand that…
I appreciate you for…
Thank you for…

This exercise can be used when a client feels stuck in emotions. Feelings need to be expressed in order to be released and for healing to occur. This is a safe and highly effective method for releasing and confronting feelings.

Technique: Using Confrontation to Improve Relationships

Counseling Intention To enable couples to express honest feelings of anger in a safe way.

Description Each couple or family takes turns to discuss the following:
• The things you do to make me angry are…”
• The things you do that most block our relationship are…”
• The things you do to improve the relationship are…”

Each individual is provided with the opportunity to confront each other. Process whether the confrontation exercise enabled them to express honest feelings of anger in a safe way.

Technique: An Exercise to Deescalate Conflict

Counseling Intention To create more positive communication.

Description (1) Identify the issues that are causing the conflict. (2) Discuss the pain and concerns of the issue. (3) Identify the consequences of each other's actions. (4) The offender in the relationship asks for forgiveness and apologizes. (5) The offended agrees to forgive and not use the issue in the future, or bring up the past in the present. (Note: Bringing up the past is disrespectful.) The offender agrees to change his or her behavior.

Technique: Problem Solving for Couples

Counseling Intention To resolve conflict and disagreements.

Description Nine ways to resolve conflicts in relationships:
1. Show respect. Don't belittle your mate or call him or her names.
2. Focus on the problem. Describe behavior, not aspects of the other's personality.
3. Tackle one problem at a time. Stay on task and don't bring in other issues.
4. Use a time out. When losing control, call for a time out and resume discussing the issue later.
5. Listen for the feelings under the words. Everything discussed is important and should be valued.
6.Don't try to be a mind reader. Clarify what your partner thinks and feels.
7. Try to see your partner's point of view. Validate your partner's feelings by acknowledging his or her viewpoint.
8. Try to solve the problem. Say: “What can we do to solve the problem?” and “I am willing to do the following…” Say it and do it.
9. Forgive and accept each other.

Technique: How to Conduct a Couples Meeting

Counseling Intention To air grievances without conflict (Notarius & Markam, 1993, p. 204).

Description The following guidelines can foster a climate of respect and shared understanding:
1. Make a date. Set up a regular weekly time for half an hour to talk with each other.
2. Focus on the problem. Sit down face to face with no distractions (i.e., no children, television, computer, or telephone) and talk about one subject at a time.
3. Use the speaker-listener tool. Decide what will be talked about and who is the speaker. Write on a piece of paper the world “FLOOR.” Rotate the FLOOR back and forth and speak only when the FLOOR is in possession. The speaker should keep his or her statements short so that the listener can follow them.
4. Don't blame and attack. Remember the problems that interfere with a more positive relationship are between the couple. The clients should focus on how each feels and their role in the problem.
5. Reserve the right to take a break. When the discussion starts to not go well (e.g., one partner starts to blame, attack, or escalate the conflict), either partner can call stop to the action. At that point in the meeting, agree to stop talking and pick up the conversation again within 24 hours.


Technique: Let's Make a Date

Counseling Intention To provide more enjoyable activities in a couple's life (Notarius & Markam, 1993).

Description Clients should make a list of fun activities to be enjoyed during an agreed-upon time period.
• Plan a surprise weekend for your spouse/lover, making sure the other person does not know the destination.
• Spend a night at a bed-and-breakfast.
• Go on a one-day cruise to nowhere.
• Learn a new sport or game to play together (e.g., golf lessons, tennis lessons, dance lessons, backgammon, or sailing).
• Take a limo ride to a favorite restaurant.
• Go browsing through antique shops.
• Decide not to watch television for a week. Tape the shows and watch them all at one sitting, leaving more time for fun activities.
• Pack a picnic dinner and watch the sun set.
• Leave love notes, candy, or other surprises in his or her briefcase or purse.

The list is endless and can be individualized to couples' needs and resources.

Technique: The Simulated Family Approach

Counseling Intention To explore family roles and gain insight into one's behavior and its effect on others.

Description The various family members simulate each other's behaviors; for example, the daughter plays the father, the father plays the stepson. The members may also be asked to pretend they are a different family. The therapist and family discuss how they differ from or identify with the roles they project.

Technique: “Family Sayings”

Counseling Intention To encourage self-awareness, expectations, and transgenerational belief systems.

Description Every family has its own favorite expressions, belief system, slogans, warnings, or counsel. Have members list all the repetitive expressions they recall from their childhood. For example, “Father knows best” may be interpreted as you have no opinion of your own; “What will the neighbors think?” may be interpreted as not to let anything tarnish our public fa├žade; or “One man's trash is another man's treasure” may be warning not to discard anything!

Have members list all the repetitive expressions that they can recall from childhood. Process the underlying messages. What values do they represent? How do they influence growth or impede independence?

Technique: Family Sculpture

Counseling Intention To assess communication and relationships.

Description Ask someone in the family to describe a typical family argument, and then have the person sculpt the argument by placing each family member in appropriate positions-complete with gestures, facial expressions, and touch. This can be followed by asking each of the other members how he or she would change it and letting each make the changes.

Technique: “All Tied up”

Counseling Intention To better understand the complexity of relationships and crossed transactions.

Description Each family member takes some long ropes, one for each of the others in the family, and ties all the ropes around his or her waist. Next, instruct them to tie one rope to each of the other family members. Process the resulting tension and mass of ropes to help the family understand the complexity of its relationships and crossed transactions.

Technique: Developing a family History

Counseling Intention To see how family members evaluate the impact of major events in the family (Richardson, 1987).

Description Using index cards, chronologically list the major events in the history of the family. Beside the dates, list any major world events that coincide with family events. Also, note the impact that any particular event had on the family.

Have the client show the cards to as many family members as he or she can.
Can the client account for any discrepancies in the dates that different family members assign to different events? How do different family members evaluate the impact of major events on the family?

Technique: Helping Survivors of Abuse

Counseling Intention To help cleanse the survivor of negative family energy.

Description Have everyone write down on small pieces of paper the names of family members who hurt them, or with whom they feel they have negative ties. Have one participant put his or her pieces of paper in the trash can, and then set them on fire. As the papers burn, tell that person to imagine the negative energies, issues, and improper bonds going up to the universe with the rising smoke. When the paper is burnt, empty the cauldron. Ashes should be given back to the participant to be disposed of as she wishes. Once everyone is finished, affirm that the negative energies of the family members listed and burned are now as ephemeral as the smoke.

INTERACTIVE THERAPEUTIC APPROACHES: FILIAL PLAY THERAPY

Filial play therapy is a psychoeducational intervention model in which the therapist trains and supervises the parents as they hold special child-centered play sessions with their own children. Parents are viewed as partners in the therapeutic process and the primary change agents for their own children. A combination of family therapy and filial play therapy can serve to eliminate presenting problems, improve parent-child relationships, and strengthen the family system. Filial play therapy has been used successfully with many child and family problems such as aggression, anxiety, depression, abuse/neglect, single parenting, adoption/foster care, relationship problems, divorce, family substance abuse, oppositional behaviors, toileting difficulties, attention problems, trauma, chronic illness, stepparenting, and multiproblem families. It can be used individually or in groups for prevention, intervention, or remediation. Families who have participated in filial therapy often continue their special play sessions, reporting that both children and parents truly benefit from this therapeutic approach. A filial therapy playroom looks much like a child-centered play therapy room. A variety of toys that can be used in imaginative and expressive ways by children are scattered in an inviting manner around the playroom.

Family-Related and Nurturance Toys
• Doll family (mother, father, brother, sister, baby)
• Doll house/furniture
• Puppet family and animal puppets
• Baby doll
• Dress-up clothes
• Baby bottles
• Container with water
• Bowls for water
• Kitchen dishes

Aggression-Related Toys
• Bop bag
• Dart guns with darts
• Small plastic soldiers and/or dinosaurs
• 6- to 10-foot piece of rope
• Foam aggression bats

Expressive and Construction Toys
• Crayons or markers and drawing paper
• Play-Doh, Sculpey, or other modeling substance
• Sand tray with miniature toys
• Plastic telephones
• Scarves or bandanas
• Blocks or construction toys
• Heavy cardboard bricks
• Blackboard
• Mirror
• Masking tape
• Magic wand
• Masks

Other Multiuse Toys
• Cars, trucks, police cars, ambulances, fire trucks, school buses
• Playing cards
• Play money
• Ring-toss or similar game
• Doctor's/nurse's kit

Technique: How to Resolve Family Conflicts

Counseling Intentions To resolve conflict collaboratively.

Description Clarify the problem. The parent moderator should introduce the general nature of the problem, then use the “go around” technique to get each person's view of the problem.

1. Go Around Questions: What is the problem as you see it? How does it affect you? What is your contribution to the problem?
2. These are challenging questions. The family should listen to each speaker with respect and an attempt at understanding. Avoid interrupting or becoming defensive.
3. The moderator should write down the points of agreement and disagreement as they arise.
4. Brainstorm solutions. Go around as many times as necessary to come up with a list of possible solutions to the problem. Don't analyze the solutions now; just write them all down.
5. Go through the list of possible solutions to narrow them down to the best solution for all family members.
6. Use the “go around' technique to get each person's view on what is the best solution for everyone. Ask “Which of these do you think is the best solution? Why? Is it fair to everyone?”
7. Select the best solution. Get commitment from each person to make the solution work.
8. Decide what each person will do to implement the solution. This is the time to come up with responsibilities, rewards, limits, consequences, and other agreed upon commitments.
9. Go around one more time with each family member stating what specific action they will take to solve the problem.

Technique: Reframing

Counseling Intention To join with the family and offer a different perspective on presenting problems (Sherman & Fredman, 1986).

Description Reframing involves taking something out of its logical context and placing it in another category. For example, a mother's repeated questioning of her daughter's behavior after a date can be seen as genuine caring and concern rather than a nontrusting parent. Through reframing, a negative often can be reframed into a positive.

Technique: Family Sculpting

Counseling Intention To re-create the family system (Duhl, Kantor, & Duhl, 1973).

Description Family sculpting provides for re-creation of the family system, representing family members' relationships to one another at a specific period of time. The therapist can use sculpting at any time in therapy by asking family members to physically arrange the family. Adolescents often make good family sculptors, as they are provided with a chance to nonverbally communicate thoughts and feelings about the family.

Technique: Family Photos

Counseling Intention To provide a wealth of information about past and present functioning.

Description One use of family photos is to go through the family album together. Verbal and nonverbal responses to pictures and events are often quite revealing. Adaptations of this method include asking members to bring in significant family photos and discuss reasons for bringing them, and locating pictures that represent past generations. Through discussion of photos, the therapist often more clearly sees family relationships, rituals, structure, roles, and communication patterns.

Technique: Draw Your Family Table

Counseling Intention To have family members examine the impact of their family of origin and/or current family dynamics on their personality and interpersonal dynamics (Trotzer, 1986).

Description
1. On a large sheet of paper, draw the shape of the table your family ate at when you were growing up, between the ages of 7 and 18.
2. Place members of your family around the table in their usual places, using squares to represent males and circles to represent females. Identify each person by name and role (e.g., mother, brother, grandfather).
3. By each member of the family at the table write a descriptive phrase or comment that describes each family member's personality.
4. On the surface of the table, write descriptors (words or phrases) that describe the atmosphere of the family and what it was like living with that family.
5. Have each member share his or her table with the group. Process the impact of the family of origin.

Technique: Family-0-Gram

Counseling Intention To examine communication dynamics in the family (Trotzer, 1986).

Description Using the family table drawing, have a group member represent each person at the table, including the client who drew the table. Have the person who drew the table give a verbal description of each family member and specify typical statements that family members would make. Each “family member” is to remember the statement and present it in the character of the family member described.

1. Once the description and statements have been assigned, place the person who drew the table in the center and form the other members around him or her in the manner depicted by the family table.

2. Starting with a parent figure, have the table's drawer face that person and make eye contact. When the drawer does this, the family member must make the statement in character. The table drawer then rotates to the next person on the right, repeating the procedure until each family member has given his or her statement to the table drawer in the center. Repeat the rotation at least three times without interruption.

3. After three rotations, have the family members move in closer to the table drawer in the center. Instruct him or her to close his or her eyes and then have all the family members make their statements once, trying to get the attention of the table drawer in the center.

After 15 to 20 seconds, stop the procedure and process the experience with the table drawer. Process the experience with all participants.

Technique: Family Council Meetings

Counseling Intention To assign families homework to follow through on therapy between sessions.

Description Family council meetings are organized to provide specific times for the family to meet and share with one another. The therapist might prescribe council meetings as homework, in which case a time is set and rules are outlined. The council should encompass the entire family, and any absent members have to abide by decisions. The agenda may include any concerns of the family.

Attacking others during this time is not acceptable. Family council meetings help provide structure for the family, encourage full family participation, and facilitate communication.

Technique: Strategic Alliances

Counseling Intention To encourage a family member to change.

Description This technique, often used by strategic family therapists, involves meeting with one member of the family as a supportive means of helping that person change. Individual change is expected to affect the entire family system. The individual is often asked to behave or respond in a different manner. This technique attempts to disrupt a circular system or behavior pattern.

Technique: Getting Rid of the Seven Deadly Habits of Unhappy Couples

Counseling Intention To help clients see that all purposeful behavior is chosen and to understand choice theory (Glasser, 1999).

Description Choice theory explains that, because clients can only control their own behavior, when a client is having difficulty with another person he or she try to choose behaviors that would bring them closer. The therapist explains that there are seven deadly external control habits that eventually will destroy the happiness in any relationship. It is almost certain that they are both using one or more of these habits in their marriage: (1) criticizing, (2) blaming, (3) nagging, (4) complaining, (5) threatening, (6) punishing, and (7) rewarding to control or bribe.

Assign homework to the couple that they should complete separately, writing down examples of when each uses one or more of the seven habits consistently in their marriage.

Once they believe they understand the difference between using external control language and choice theory language, they should together discuss how they could rewrite the examples they had written down. Their task would be to change their words from external control to choice theory language. Process how their lives and their marriage will improve significantly.

Technique: Mission and Legacy

Counseling Intention To encourage couples to write about some aspects of their life and personality that will help them as spouses to understand each other better (Gottman, 1999, p. 211).

Description

“Imagine that you are standing in a graveyard looking at your own tombstone. Think of the epitaph you would like to see there. Imagine your own obituary in the newspaper following your death. Write this obituary of yourself-it does not have to be brief. How do you want people to think of your life, to remember you?

“Next, write the mission statement for your life. What are you trying to accomplish? What is your larger struggle? What is you dream? What legacy would you like to leave this world when you die?

“What are your life dreams? What is that you definitely want to do in your life that you have not yet fulfilled? This can be creating something or on an experience that you want to have, such as learning to sail, climbing a mountain, or parachuting out of an airplane.”

Process that involvement in what is wanted most is a process of becoming.
“What kind of person do would you like to be? What have been your struggles in trying to become that person?”

Technique: Deposits in an Emotional Bank Account-Stress-reducing Conversations

Counseling Intention To enhance the couple's ability to create a peaceful home by learning how to have a stress-reducing conversation on a daily basis (Gottman, 1999, p. 214).

Description “Tell the couple that this exercise deals with the management of daily external stress, like job stress. Ask spouses to commit to having a conversation like this one every day, for at least 20 minutes at the end of the day. Ask the spouses to discuss a recent or upcoming stress in each of their lives that is not related directly to a marital issue (i.e., upcoming visit from toxic in-laws, or a business venture). They take turns, allowing about 15 minutes for each. In the last five minutes of the exercise, ask the partners to discuss how and when they could build in this kind of conversation into each day.”

Technique: Diffusing Physiological Arousal by Taking a Structured Break

Counseling Intention To introduce a “withdrawal ritual” or “time out” procedure in the marriage to manage stress (Gottman, 1999, p. 231).

Description Have the couple discuss the following questions. There is no blaming.
1. What makes me feel flooded (overwhelmed)? What are the feelings inside me when this happens? What am I thinking usually?
2. How do I typically bring up issues or complaints?
3. Do I store things up?
4. Is there anything I can do that soothes you?
5. Is there anything I can do to soothe myself?
6. What signals can be developed for letting the other know when one of us is feeling flooded? Can we take breaks? (This is the most important part of the exercise.)

Technique: Working as a Team: The Paper Tower

Counseling Intention To help the couple work as a team by turning toward each other rather than away from one another, and giving and accepting influence in an equitable sharing of power on a task that is unrelated to marital issues (Gottman, 1999, p. 293).

Description The couple is given a box containing assorted materials such as newspapers, magazines, construction paper, tape, sparkling glue, magic markers, stickers, straws, string, stapler, and anything else to make the box interesting. They are instructed to build a paper tower. It must be tall, strong, and beautiful, and has to be able to stand unsupported. They can earn up to 25 points for size, 25 points for strength, and 50 points for beauty. The points are awarded by the therapist, who also gives the spouses feedback on how they worked together as a team. The most influential team member is the one who draws out the other, asks questions, and gives support, rather than the one who dominates.

Technique: Solution-Focused Family Techniques

Counseling Intention Identify and amplify solution patterns (deShazer, 1982, P. 42).

Description Increase cooperation by accepting the clients' goals framed in a realistic, positive way. Maintain an overtly supportive, accepting therapeutic stance.

Stay solution-focused:

1. Initial changes are small.
2. Clients' intermittent return to problem talk is not a failure.
3. Measure success by goal attainment, not by number of sessions.

Ask solution-focused questions and expand the answers with the following questions:

1. Exceptions: “What things are different when the problem is not happening?”
2. Miracles: “Let's pretend a miracle occurred while you were sleeping. What would you notice when you awoke that would tell you the problem was gone?”
3. Scaling: “On a scale of 1 to 10, where are you now? What would you prefer? What could you do to advance 1 point?”
4. Coping: “What do you do to keep things from being worse? How did you get through such a difficult thing?”
5. Increasing readiness to notice change: “It will be interesting to see how things change for the better this week.”
6. Solution tasks: “Between now and the next time we meet, notice what is going right that you do not want to change (p. 42).”

Chapter 13 - Trauma, Loss, Grief, and Post-Traumatic Stress Debriefing

Lecture Notes
Chapter 13 - Trauma, Loss, Grief, and Post-Traumatic Stress Debriefing
Counseling Techniques – Rosemary Thompson
Instructor - Jeff Garrett Ph.D.



TASKS OF MOURNING AND GRIEF COUNSELING


The tasks of mourning and grief counseling include the following:

• To accept the reality of the loss and to confront the fact that the person is dead. Initial denial and avoidance becomes replaced by the realization of the loss.
• To experience the pain of grief. It is essential to acknowledge and to work through this pain or it will manifest itself through self-defeating behavior(s).
• To adjust to an environment in which the deceased is missing. The survivor(s) must face the loss of the many roles the deceased person filled in their life.
• To withdraw emotional energy and reinvest it in another relationship. Initial grief reaction to loss may be to make a pact with oneself never to love again. One must become open to new relationships and opportunities.
• To accept the pain of loss when dealing with the memory of the deceased.
• To express sorrow, hostility, and guilt overtly, and to be able to mourn openly.
• To understand the intense grief reactions associated with the loss; for example, to recognize that such symptoms as startle reactions, including restlessness, agitation, and anxiety, may temporarily interfere with one's ability to initiate and maintain normal patterns of activity.
• To come to terms with anger, which often is generated toward the one who has died, toward self, or toward others-to redirect the sense of responsibility that somehow one should have prevented the death.

Grinspoon’s suggestions for counselors dealing with a client who is experiencing PTSD

Grinspoon (1991a, b) provided 17 suggestions for counselors dealing with a client who is experiencing PTSD:

• Provide a safe environment for confronting the traumatic event.
• Link events emotionally and intellectually to the symptoms.
• Restore identity and personality.
• Remain calm while listening to horrifying stories.
• Anticipate one's own feelings or responses and coping skills-dread, disgust, anger at clients or persons who had hurt them, guilt, or anxiety about providing enough help.
• Avoid overcommitment and detachment.
• Avoid identifying with the client or seeing oneself as rescuer.
• Tell the client that change may take some time.
• Introduce the subject of trauma to ask about terrifying experiences and about specific symptoms.
• Moderate extremes of reliving and denial while the client works through memories of trauma.
• Provide sympathy, encouragement, and reassurance.
• Try to limit external demands on the client.
• During periods of client numbing and withdrawal, pay more attention to the traumatic event itself.
• Help client bring memories to light by any means possible including dreams, association, or fantasies.
• Examine photographs and old medical records; for children, employ play therapy, dolls, coloring books, and drawings.
• Employ special techniques, systematic desensitization, and implosion to eliminate conditioned fear of situations evoking memories and achieve catharsis.
• Facilitate group therapy.

TEN WAYS TO RECOGNIZE POST-TRAUMATIC STRESS DISORDER

Post-traumatic stress disorder is in many ways a normal response to an abnormal situation. Clearly, the tragedies that occurred on September 11, 2001, were unprecedented. After such a tragic event, it is likely that many will experience a variety of symptoms and emotions. Sometimes these symptoms surface several weeks or months after the tragedy in the form of PTSD. Recognizing these symptoms is the first step toward recovery and finding appropriate treatment:
1. Reexperiencing the event through vivid memories or flashbacks.
2. Feeling “emotionally numb.”
3. Feeling overwhelmed by what would normally be considered everyday situations and diminished interest in performing normal tasks or pursuing usual interests.
4. Crying uncontrollably.
5. Isolating oneself from family and friends and avoiding social situations.
6. Relying increasingly on alcohol or drugs to get through the day.
7. Feeling extremely moody, irritable, angry, suspicious, or frightened.
8. Having difficulty falling or staying asleep, sleeping too much, and experiencing nightmares.
9. Feeling guilty about surviving the event or about being unable to solve the problem, change the event, or prevent the disaster.
10. Feeling fears and sense of doom about the future.

The child/adolescent assessment of post-traumatic stress (Table 13.1) can be used as a tool to normalize terrifying feelings and identify potential high-risk youth. It is important to explain that these are normal reactions to a traumatic or catastrophic event.

TABLE 13.1
Child/Adolescent Assessment of Post-traumatic Stress
Answer yes or no:
_____I think about the accident more than I want to.
_____I dream about the incident.
_____I feel numb some of the time.
_____I have difficulty talking about my thoughts and feelings.
______I get depressed easily, sometimes to the point of not wanting to live.
______I find it hard to get close to friends, teachers, and family members.
______I can't seem to make my friendships work.
______I avoid things that may remind me of the accident.
______I hardly ever feel happy.
______I feel guilty that I survived when others didn't.
______I feel scared, nervous, and jumpy.
______I look around a lot to see if something can hurt me.
______ I can't sleep.
______ I can't eat.
______I have trouble remembering things.
______I can't pay attention.
______I get angry and frustrated a lot.
______I worry I'll get too angry and hurt someone or something.
______I can't figure out what's bothering me.
______I feel hopeless and sad.

Source: Montgomery County Public Schools and Montgomery County Crisis Center, Blacksburg, Virginia; and Goldman, 1999.

THERAPEUTIC APPROACHES TO PROCESS POST-TRAUMATIC STRESS DISORDER

Both medication and psychotherapy can be helpful. The most effective treatment approaches are “cognitive-behavioral” because they focus both on the way traumatized persons view the trauma and on their resulting behavior. Exposure therapy includes systematic desensitization (training to relax in the face of frightening reminders of the trauma) and imaginable, in vivo techniques such as flooding or the process of putting the client back into the trauma psychologically. The most effective treatment for PTSD includes a variety of anxiety management training strategies. Some of these include rational emotive therapy (RET), various kinds of relaxation training, stress inoculation training, cognitive restructuring, breathing retraining, biofeedback, social skills training, and distraction techniques. Innovative therapists are successful in combining various techniques to fit the trauma and the patient's unique needs and requirements.

Post-traumatic loss Debriefing
Post-traumatic loss debriefing is a structured approach to understand and to manage physical and emotional responses of survivors and their loss experiences. It creates a supportive environment to process blocked communication, which often interferes with the expression of grief or feelings of guilt, and to correct distorted attitudes toward the deceased as well as to discuss ways of coping with the loss. The purpose of the debriefing is to reduce the trauma associated with the sudden loss, to initiate an adaptive grief process, and to prevent further self-destructive or self-defeating behavior. The goals are accomplished by allowing for ventilation of feelings, exploration of symbols associated with the event, and enabling mutual support.The debriefing is composed of six stages: introductory stage, fact stage, feeling stage, reaction stage, learning stage, and closure. Successful resolution and psychological well-being are dependent upon interventions that prepare individuals for periods of stress and help survivors return to their precrisis equilibrium. A debriefing should be organized 24 to 72 hours after the death. Natural feelings of denial and avoidance predominate during the first 24 hours. The debriefing can be offered to all persons affected by the loss. The tone must be positive, supportive, and understanding.

Technique: Post-Traumatic loss Debriefing

Counseling Intention To process loss and grief; to inform participants about typical stress response and implications (Figley, 1998; Schiraldi, 2000; Thompson, 1990, 1993).

Description of Introductory Stage. This stage includes brief introductions to the debriefing process and establishment of rules for the process.

• Acting as caregiver-as-facilitator, define the nature, limits, roles, and goals within the debriefing process.
• Clarify time limits, number of sessions, confidentiality, possibilities, and expectations to reduce unknowns and anxiety for survivors.
• Encourage members to remain silent regarding details of the debriefing, especially details that could be associated with a particular individual.
• Assure participants that the open discussion of their feelings in a debriefing will in no way be used against them under any circumstances.
• Give reassurances that the caregiver-as-facilitator will continue to maintain an attitude of unconditional positive regard. Reduce the survivors' initial anxieties to a level that permits them to begin talking.

Description of Fact Stage. The fact stage includes warm-up, gathering information, and recreating the event. During the fact phase, participants are asked to recreate the event for the therapist. The focus of this stage is on facts, not feelings. Encourage individuals to engage in a moderate level of self-disclosure statements, such as “I didn't know about that. Could you tell me what that was for you?” Try to achieve an accurate sensing of the survivor's world and communicate that understanding to him or her. Be aware of the survivor's choices of topics regarding the death to gain insight into their priorities for the moment. To curtail self-blaming, help survivors see the many factors that contributed to the death. Ask group members to make a brief statement regarding their role, relationship with the deceased, how they heard about the death, and circumstances surrounding the event. Have group members take turns adding in details to make the incident come to life again. This low initial interaction is a nonthreatening warm-up and naturally leads into a discussion of feelings in the next stage. It also provides a climate to share the details about the death and to prevent secrets or rumors that may divide survivors.

Description of Feeling Stage. The feeling stage includes expression of feelings surrounding the event and exploration of symbols. At this stage, survivors should have the opportunity to share the burden of feelings that they are experiencing and be able to do so in a nonjudgmental, supportive, and understanding environment. Survivors must be permitted to talk about themselves, to identify and to express feelings, to identify their own behavioral reactions, and to relate to the immediate present, the here-and-now.

An important aspect of this stage is for the caregiver-as-facilitator to communicate acceptance and understanding of the survivor's feelings. Acceptance of the person's feelings often helps him or her feel better immediately. It also can serve as a developmental transition to a healthier coping style in the future. Thoughtful clarification or reflection of feelings can lead to growth and change, rather than self-deprecation and self-pity.

Each person in the group is offered an opportunity to answer a variety of questions regarding their feelings. Often survivors will confront the emotion of anger and where their feeling is directed. It is important that survivors express thoughts of responsibility regarding the event and process the accompanying feelings of sadness.

At this stage, care must be taken to ensure that no one gets left out of the discussion, and that no one dominates the discussion at the expense of others. At times, the therapist has to do very little. Survivors have a tendency to start talking and the whole process goes along with only limited guidance from the therapist. People will most often discuss their fears, anxieties, concerns, feelings of guilt, frustration, anger, and ambivalence. All of their feelings-positive or negative, big or small-are important and need to be expressed and listened to. More importantly, this process allows survivors to see that subtle changes are occurring between what happened then and what is happening now.

Description of Reaction Phase. The reaction stage explores the cognitive and physical reactions and ramifications of the stress response. Acute reactions can last from a few days to a few weeks. Inherently, the survivor wants to move toward some form of resolution and articulates that need in terms such as “I can't go on like this anymore, ” “Something has got to give, ” “Please help me shake this feeling, ” or “I feel like I'm losing my mind.” Typical anxiety reactions are a sense of dread, fear of losing control, or the inability to focus or to concentrate.

• The caregiver-as-therapist asks such questions as “What reactions did you experience at the time of the incident or when you were informed of the death?” and “What are you experiencing now?” These subtle questions allows them to see they are getting better day by day.
• The caregiver-as-therapist encourages clients to discuss what is going on with them in their peer, school, work, and family relationships.
• To help clarify reactions, the caregiver-as-therapist may provide a model for describing reactions, such as the focus of “ownership+feeling word+description of behavior.” For example, “I am afraid to go to sleep at night since this has happened, ” or “I feel guilty about not seeing the signs that he was considering suicide.”

Description of Learning Stage. The learning stage, for understanding of posttraumatic stress reactions to loss, is designed to assist survivors in learning new coping skills to deal with their grief reactions. It also is therapeutic to help survivors realize that others are having similar feelings and experiences. The caregiveras-therapist assumes the responsibility to teach the group something about their typical stress response reactions. The emphasis is on describing how typical and natural it is for people to experience a wide variety of feelings, emotions, and physical reactions to any traumatic event. It is not unique but is a universally shared reaction. Critical to this stage is to be alert to danger signals to prevent negative destructive outcomes from a crisis experience and to help survivors return to their precrisis equilibrium and interpersonal stability.

This stage also serves as a primary prevention component for future self-defeating or self-destructive behaviors by identifying the normal responses to a traumatic event in a secure, therapeutic environment with a caring, trusted adult.
Description of the Closure Stage. The closure stage includes wrap-up of loose ends, questions and answers, final reassurances, action planning, referrals, and follow-up. Human crises that involve post-traumatic stress often, if debriefed appropriately, serve as catalysts for personal growth.

Phases of Recovery

Peter and Straub (1992, pp. 246-247) classified the recovery process as four phases.

1. Emergency or Outcry Phase. The survivor experiences heightened “fight or flight” reactions to the life-threatening event. This phase lasts as long as the survivor believes it to last. Pulse, blood pressure, respiration, and muscle activity are all increased. Concomitant feelings of fear and helplessness predominate. Termination of the event itself is followed by relief and confusion. Preoccupation centers around questions about why the event happened and the long-term consequences.

2. Emotional Numbing and Denial Phase. The survivor shelters psychic well-being by burying the traumatic experience in subconscious memory. By avoiding the experience, the victim temporarily reduces anxiety and stress responses. Many survivors may remain at this stage unless they receive professional intervention.

3. Intrusive-Repetitive Phase. The survivor has nightmares, mood swings, intrusive images, and startle reactions. Overreliance on defense mechanisms (e.g., intellectualization, projection, or denial) or self-defeating behaviors (e.g., abuse of alcohol or other drugs) may become integrated into coping behaviors in an effort to repress the traumatic event. At this juncture, the delayed stress becomes so overwhelming that the survivor may either seek help or become so mired in the pathology of the situation that professional intervention becomes necessary.

4. Reflective-Transition Phase. The survivor is able to put the traumatic event into perspective. He or she begins to interact positively and constructively with a future orientation and exhibits a willingness to put the traumatic event behind him or her.

Technique: Clinical Interventions

Counseling Intention To help clients through phases of grief and loss.

Description Rando (1984) provides the following clinical interventions for caregivers when confronting dying, grief, and death.
• Be present emotionally as well as physically to provide security and support.
• Do not allow grievers to become socially isolated.
• Make certain that grievers have the appropriate medical evaluation and treatment available if symptoms warrant.
• Encourage the verbalization of feelings and recollections of the deceased.
• Help grievers identify any unfinished business with the deceased and look for appropriate ways to assist closure. (One way that comes to mind is having the client write a letter to the deceased.)
• Help grievers find a variety of new sources of personal satisfaction following the loss. Encourage grievers to be patient and not set unrealistic expectations for themselves.
• Help grievers to recognize that loss always brings about change and the need for new adjustments.
• Assist grievers in getting and maintaining a proper perspective on what the resolution of grief will mean.
• Encourage grievers, at the appropriate time, to find rewarding new things to do and people to invest in.

Technique: Multiple Strategies to Process Grief and Loss

Counseling Intention To meet the diversity of needs when processing loss (Miller, 2003).

Description Many strategies are available to help people who are mourning a loved one's death. Different kinds of losses dictate different responses, so not all strategies will suit everyone. Equally, no two people grieve alike, so what works for one may not work for another.

Carry or Wear a Linking Object. Carry something that belonged to the one who died-a keepsake, a small object, or a memento. Wear a piece of their jewelry in the same way. Look at the keepsake and remember what it signifies.

Create a Memory Book. Compile photographs that document a loved one's life. Arrange them into some sort of order so they tell a story. Add other elements such as diplomas, newspaper clippings, awards, accomplishments, and reminders of significant events. Put all this in a special binder and keep it out for people to look at if they wish. Go through it and reminisce about positive experiences of the past.

Ask for a Copy of the Memorial Service. If the funeral liturgy or memorial service held special meaning because of what was spoken or read, ask for a copy of the words. Whoever participated in that ritual will feel gratified that what they prepared was appreciated. Some people find these thoughts provide even more help weeks and months after the service.

Start a Journal. Write out thoughts and feelings. Do this at least several times a week, if not several times a day. Don't censor what is written. Let feelings flow. In time, go back over what was written and notice change and growth. Write about that, too.

Write to the Person Who Died. Write letters or other messages to the deceased, especially thoughts that were not express when that person was alive. Preserve what you write in a journal. The urge to write the deceased will eventually diminish. Initially, writing serves to release of important emotions and to provide a connection to the deceased.

Light a Candle at Mealtime. Consider lighting a taper at the table in memory of a loved one. Pause to remember the deceased and keep him or her nearby.
Create a Memory Area at Home. In a space that feels appropriate, arrange a small table that honors the person: a framed photograph or two, perhaps a prized possession or award, or something he or she had created or loved. This might be placed on a small table, a mantel, or a desk. Some people like to use a grouping of candles, representing not just the person who died but others who have died as well. In that case, a variety of candles can be arranged, each representing a unique life.

Structure Alone Time. Structure time to be alone. A large part of the grieving process involves what goes on inside-absorbing the thoughts, feelings, memories, hopes, and dreams. Allow the opportunity to go inside in order to grow inside.

Do Something the Deceased Would Enjoy. Remember the one who died in a unique way. For example, prepare a loved one's favorite dish on significant holidays. The meaning and satisfaction doesn't have to end with the death of that person.

Engage the Soul. Some people meditate, some pray, and some spend time alone in nature. Some worship with a congregation and others do it on their own. Many grieving people begin to sense that all of the human race, living and dead, are connected on a spiritual level in a way that defies understanding.

Change Some Things. As soon as it seems right, alter some things in the home environment to make clear a significant change that has occurred. Rearrange a room, replace a piece of furniture, or give away certain items that will never be used again. This does not mean to remove all signs of the one who died. It does discourage treating the home as a shrine, which would be unhealthy grieving.

Talk to the Deceased Loved One. If it helps, talk with the one who died while driving, walking, or when needing the courage to make an important decision. This self-talk serves the need to talk things over or to process unfinished conversations. This inclination to converse will eventually go away, when the time is right.

Create a Memory Quilt. Sew or invite others to sew a memory quilt. Put together a wall hanging or a bedroom quilt that remembers the important life events of the one who died. Take time and make it what it is: a labor of love.
Read How Others Have Responded to a Loved One's Death. Look at the ways others have processed grief, try Judith Viorst's Necessary Losses (1986), C.S. Lewis's A Grief Observed (1963), Lynn Caine's Widow (1974), John Bramblett's When Good-Bye Is Forever (1991), and Nicholas Wolterstorff's Lament for a Son (1917). There are many others. Check with a counselor or a librarian.

Reward Personal Growth. Do things that are personally rewarding. Indulge in a favorite meal or delicacy. Get a massage. Buy some flowers. Do something frivolous and soak up those moments.

Write Down Lessons Learned. The grief experience is a learning process. Reflect upon what has been learned. State it plainly and review it routinely.

Technique: Make a “Tear Jar”

Counseling Intention To process grief (White, [n.d.], reprinted with permission).

Description In the dry climate of ancient Greece, water was a precious commodity. Giving up water from one's own body, when crying tears for the dead, was considered a sacrifice. They caught their precious tears in tiny pitchers or “tear jars.” The tears became holy water and could be used to sprinkle on doorways to keep out evil, or to cool the feverish. The clay tear jars were kept unpainted until the owner had experienced the death of a parent, sibling, child, or spouse. After that, the grieving person decorated the tear jar with intricate designs. This ancient custom symbolizes the transformation that takes place in people who have grieved deeply. They are not threatened by the grief of people in pain. They have been in the depths of pain themselves, and returned. Like the tear jar, they can now be with others who grieve and catch their tears.

Technique: Resolving Grief by Remembering the Good Feelings Such as love, Comfort, Stability, Tenderness, and Humor

Counseling Intention To create an “associated experience” that gives the grieving person a sense of a loved one's “felt presence” (Andreas & Andreas, 1989).

Description The first step in resolving grief is to find out how the client represents a loved one in “felt presence.” Ask the client to think of a loved one who is not physically present. Ask the client to visualize the time the valued relationship actually occurred and identify “present-felt sense of love and comfort.” Use this information as a “template” to transform the grief experience into the felt presence in which the client can enjoy previously felt good feelings.
'Next, have the client focus on the special qualities of the relationship that he or she had with the deceased-the love, comfort, stability, companionship, or whatever special experiences existed between them. Use the template of the felt presence to transform the loss experience into an “associated image” from which the client can reexperience the good feelings previously felt. The client regains access to all the special feelings he or she previously had with that person.

Loss, Crisis, and Grief: Special Considerations for Children

The intense anxiety and fear that often follow a disaster or other traumatic event can be especially troubling for children. Some may regress and demonstrate younger behaviors such as thumb-sucking or bed-wetting. Children may be more prone to nightmares and fear of sleeping alone. Performance in school may suffer. Other changes in behavior patterns may include throwing tantrums more frequently, or withdrawing and becoming more solitary. There are several things parents and others who care for children can do to help alleviate the emotional consequences of trauma.

• Spend more time with children and let them be more dependent on you during the months following the trauma. For example, allow the child to cling to caregivers more often than usual. Physical affection is very comforting to children who have experienced trauma.

• Provide play experiences to help relieve tension. Younger children in particular may find it easier to share their ideas and feelings about the event through non-verbal activities such as drawing.

• Encourage older children to discuss their thoughts and feelings with one another. This helps reduce their confusion and anxiety related to the trauma. Respond to questions in terms they can comprehend. Reassure them repeatedly that you care about them and that you understand their fears and concerns.

• Keep regular schedules for activities such as eating, playing, and going to bed to help restore a sense of security and normalcy.

Parents Should Be Alert to These Changes in a Child's Behavior
• Refusal to return to school and “clinging” behavior, including shadowing the mother or father around the house.
• Persistent fears related to the catastrophe (such as fears about being permanently separated from parents).
• Sleep disturbances such as nightmares, screaming during sleep, and bed-wetting, persisting more than several days after the event.
• Loss of concentration and irritability.
• Startling easily, and jumpy behavior.
• Behavior problems, for example, misbehaving in school or at home in ways that are not typical for the child.
• Physical complaints (stomachaches, headaches, dizziness) for which a physical cause cannot be found.
• Withdrawal from family and friends, sadness, listlessness, decreased activity, and preoccupation with the events of the disaster.

It is important to use the language of death when working with children. Stating that a loved one has “gone away, ” “is lost, ” or “is sleeping” can be very frightening to children and delays their accepting and understanding that the person will not come back. Children must have clear and concise information regarding the death of the loved one, or they may construct their own stories to fill in the holes. This is destructive fantasy building. Children must not be denied the opportunity to express their feelings in ways that are appropriate to them. There is considerable evidence of the resilience of children. Nourished by love, protection, guidance, and attention, they can spring back after even the most horrendous traumatic events (Johnson, 1998). The parent is often the most influential factor in the recovery of the child. When considering the developmental and social factors that determine the suitability of including the child in therapy, the therapist should assess the parents as carefully as the children, because the role the parent plays will determine whether their children can benefit from therapy (Nader, Dubrow, & Stamm, 1999). One of the goals for treatment of traumatized children is to help the child face the truth of what has happened. This involves enabling the child to draw, sing, dance, talk, or engage in some other form of self-expression that is also a self-soothing activity.

Technique: How to Help a Child or Adolescent through Denial

Counseling Intention To open the door to confront the loss of a loved one.

Description As a counselor or therapist, do not refute or debate the child or adolescent's current reality. Identify with the child/adolescent's feelings by saying “You really must be missing now, ” or “You must be feeling really lonely now.”

If the child doesn't want to talk, provide or suggest activities with continuity such as a scrapbook of photos or artwork portraying “the way things were then and the way things are now.” Include normal routines such as home, school, family, dinner time, weekends, bedtime, time alone, and holidays.

Technique: How to Help a Child through Denial after a Traumatic Event

Counseling Intention To reestablish a sense of control.

Description Make toys available to encourage reenactment play. Dolls, puppets, building blocks, cars, fire trucks, ambulances, or other imaginative toys or props can be used to duplicate the recent crisis. Help the child to find positive outcomes in their play.

Technique: How to Help an Older Child with Fear after a Death

Counseling Intention To process loss.

Description Help older children tell their story. Discuss what happened to the deceased, and how people survive a major loss. Remind them of their support of people around them. Remind them of the strengths they used in the past when a friend moved away or a pet died.

Technique: Providing Permission and Structure to End the Mourning Process

Counseling Intention To help with leaving the mourning period behind.

Description Dealing with loss differs for each client. However, one aspect that holds true is that the closer the attachment to the deceased, the greater the loss.

1. At the appropriate time, give the child/adolescent permission to cease the mourning period.
2. Help the child/adolescent choose a ritual to say goodbye.
3. Remind the child/adolescent that the memory of the relationship will never end, just the deceased's presence.
4. Explore what has been learned from the life of the deceased.
5. Help the child/adolescent plan how to make that memory a part of his or her life, such as with a linking object.
6. Encourage a reinvestment in new or forgotten activities.

Technique: Circle of Trust to Identify Support during Grief

Counseling Intention To reassure children that they have people around them whom they can count on (Goldman, 2001, pp. 109-110).

Description The trust circle strategy (Figure 13.1) can act as a preventive tool to be used as needed to create awareness of present support during a grief period and as a vehicle for discussion and communication about thoughts, feelings, and emotions children harbor within themselves about people in their lives.
1. The child pastes his or her picture in the center of the circle.
2. Help the child identify people in his or her life that he or she cares about and with whom feelings can be trusted.

I can call on these people if I need to talk or ask for something. My very most trusted people are: _________________
Their phone numbers are: _________________
Have the child write these peoples' names, draw their pictures, or paste photos of them in the innermost circle.
3. Help the child identify other people who can help, such as family, friends, teachers, neighbors, coaches, or Sunday school teacher.
There are even more people in my life I can depend on. They are: _________________
Their phone numbers are: _________________
Write their names, draw their pictures, or paste photos of them in the middle circle.
4. Help the child identify other adults who he or she likes, such as the school nurse, the school counselor, or a friend of the child's parents.
Sometimes there are people I like in my life, but I am not sure I can call them for help. They are: ___________________________________________ I would_______ or would not_________ like to be able to call on them. I will ask them for their numbers and tell them why I would like their phone numbers.
Write their name, draw their picture, or paste a photo in the outer circle.

Creating Meaningful Rituals

Creating and participating in a ritual after the immediate time period acknowledges the loss in a way that is personally significant for the bereaved. Additionally, when there is unfinished business, issues involving other types of closure, or when the family simply wants to develop a personal family way of remembering, rituals provide a method of accomplishing these ends. Some of the saddest words in the English language are “If I had only had a chance to tell him.” These words are heard countless times from the bereaved. One more chance to say goodbye, or one more opportunity for closure often haunts the bereaved for months, if not for years and generations (Cook & Dworkin, 1992). The development of the ritual must come from the client's frame of reference. It is important for clinicians to understand which religious and cultural beliefs hold particular significance for their clients and not assume that each member of the family believes in the same way. In helping the bereaved construct a meaningful ritual, the therapist may make suggestions, such as writing a letter to say goodbye, having a conversation at the grave side, or role-playing a last conversation and creating a different ending. For the ritual to have meaning, the ultimate decision and design must come from the bereaved.

Finding Closure and Preparedness

The final phase is a time for shifting to post-treatment, in which the family will return at some specified number of months as a way of assuring that the family has healed and is better prepared for life's losses. There are four useful criteria for working with traumatized families:

1. Did they reach their treatment goals?
2. Did the family develop a healing theory that all members embrace?
3. Did new rules and skills of family communications emerge?
4. Did the family experience a sense of accomplishment?

A sign of success and the end of weekly sessions is when the family members begin to act like the session is routine and regularly talk much more than the therapist. This is a sign that clients are now empowered to take back control of their lives. This places the therapist in the advantaged role of consultant, providing advice, assistance, and consultation as family members work together toward a common goal.