Your context is important since the client will interpret your
questions on the basis
of his ideas about your context.
"Is it possible to get pills to sober up (or detox)
in out-patient care?"
"Can one get sick-leave and on what conditions?"
The simple question: "How can I help?" can
therefore lead to very different answers depending on the clients ideas
about your setting.
Many people have intuitive knowledge about this. Many
of us who have worked in treatment units or institutions within the
mental-health service, has more than once tried to show clients that we
are not loyal to our units ideology. In an often desperate attempt to
escape the restrictions set by our context, we have tried to establish
relationships different from what is customary within the unit. On some
rare occasions we may also have succeeded, and on some very rare occasions
an effort of that kind has changed the direction and/or ideology of an
institution (Barbro Sandin, Frida Fromm-Reichman, Salvador Minuchin).
Different units make different demands on clients.
Think about the traditions at your workplace. Think about the differences
in what clients expect when they come to you if:
· You work in a
detoxification-unit that for many years tried to prioritize addicts
with a fare chance to continue into long-term treatment, and secondly,
for life-saving purposes has taken in extremely worn out patients.
· You are a physician
in a hospital-based unit for infectious disease with a rather generous
attitude when it comes to trying outpatient detoxification with "motivated"
patients.
· You are a social
worker in a commune that subscribes to a large number of places in an
institution using the Minnesota-model.
· You are working in an
outpatient unit with a strong bias towards doing brief
solution-focused therapy with addicts and their families, where
clients and families can seek help anonymously.
As we mentioned earlier clients can come to you for
many different reasons. One can want to stop abusing drugs or alcohol and
do something different in life. Often however it is other things that make
clients seek treatment. More or less clearly expressed coercion from
family or professional networks, increasing debts with threats that forces
the addict to withdraw from circulation for a while, etc.
This is no problem when you are respectful and listen
to your client. It only becomes a problem if you assume that the client
came because he wants to do something about his addiction, and the client
has other more important things on his mind. If you don't listen carefully
the client will not be able to talk to you about what is bothering him and
will not — at least with you — be able to construct solutions to his
problem.
Accept the client's definition of the problem, whether
it has to do with the abuse or not. Be careful to respect the descriptions
even if, and maybe even particularly so, if you see it as an excuse for
abusing. "I take amphetamines to cheer me up because I'm so tired,"
or "Life is so dull". Accept the definition even if you
understand the problem as an effect of the addiction: "I would like
to be a better mother", "My children are so difficult".
Don't connect the problem to the addiction, let the client do it if he
wants. Accept that some clients never make the connection. Our clients do
not need help to moralize – they are pretty good at that themselves. Pay
attention to when you get irritated or don't feel curiosity. Remember that
everyone is doing the best they can.
Accept vague problems like for instance: "I get so
much social problems from my drinking/abusing," but ask the client to
be specific: "How?" or rather: "Problems to who? Is this a
problem only for you or are there other people who feel the same way?"
"Would your mother agree or would she say
something else?"
When you listen with your entire self you will notice
when the problem/goal is relevant to the client.
This idea is a precondition for developing an alliance
based on co-operation. It will also help you and the client describe
resources and competence and it will help you to respect and maybe even
like the client. If you can not find good things that clients do in their
lives; you will have to make more efforts to be curious.
When we started working with addicts our attitude was
that addicts came to therapy to stop addictive behavior. We saw
detoxification and sobriety as something that should be the result of
treatment - not a precondition for treatment so detox before treatment
seemed absurd.
Later on, many addicts told us that detoxing had
problem never been a problem for them. They had done it many times. For
them the problem was how to avoid getting high again. The reasons for us
to accept to see clients that were on drugs or clients that were high have
thus differed over time but the result is the same.
Our experience is that when sessions are interesting
enough, the addict will make efforts to understand what is going on and
try to get something out of the conversations. Sometimes he will have to
reduce his abuse drastically to achieve this and does that.
We ordinarily have some information about the client
before the first session. Assume that the descriptions made are not valid.
The social-worker who made the referral said the girl was extremely
motivated to stop doing drugs, and three minutes into the session you find
out that her concern is that if she doesn't quit drugs yesterday (?), her
baby will be taken into custody the day after tomorrow.
Don't take anything for granted – ask the client!
Each one of us has our way to start a session. Use
yours in a way that you are comfortable with. Consider that when clients
come to you the first time they may not have made the decision to stop
abusing, but there is often a desire in that direction. Also consider that
motivation for change is not a characteristic within the person but
something that grows out of the interplay between you.
"What makes you seek help here now?"
"How can I be of help?"
"Imagine this will be a useful conversation for
you - what will we have talked about in an hour?"
Pay more interest to the present and future than to the
problem and the history. Listen for what the client is saying and
how he is saying it. Try and get a dynamic description of the
present.
"What is it right now that makes you in your
unique situation seek help here today?"
"Who else is involved in this decision to seek
help?"
This is more useful information than with what, why and
how the addict has been getting high or drunk.
A dynamic description of the present can be for
instance:
"My girlfriend can't stand it anymore. She has
made it clear to me that if I don't quit now, she moves out."
Or; A fifty-year old alcoholic comes to the Alcohol
Clinic’s emergency intake.
"What's your problem?" the doctor (HK) asks.
The man is very drunk, more falls into the chair, than sits down, flings
his arms out in a gesture of resignation and answers in a thick voice:
"My parents can't take it anymore."
Some clients seem to come to get a break from the
monotony of prison.
Rolle is actually very clear but
the therapist (HK) has difficulties believing what he is hearing.
"It's boring in prison and this suggestion from my
social-worker seemed a nice break. Stop doing drugs? No, I don't want
that. Do something different? What life would look like without drugs? I
can't imagine. A miracle? Miracles don't exist.
Some people don't seem to know why they've come or come
because of coincidence.
Lisa, 30 years old, with moderate abuse comes because
she is accompanying her boyfriend to his first session. It is only that he
hasn't shown, and yes, she has a small drug-problem, but that is not why
she is there.
"What does you life look like?" asks the
therapist (HK). "Well", answers she, "not to bad. I live an
exciting life. I have creative and artistic ambitions and it is not
possible to create without suffering."
"Who worries about you and thinks about how you're
doing?"
"Nobody!" she answers, but adds: "Of
course my parents are wondering but they don't know." Thoughtfully
she continues: "Maybe my older sister is worried as I told her the
day before yesterday that I am using drugs".
"So you finally told your family. Is that because
you want to change something now?"
"Well". She thinks for a long while, looks
thoughtful and says: "Not the heroin, but perhaps smoke a little less
pot. It makes one so out of it."
The easiest way to find out is to ask: "What are
you good at?" Sometimes the client wonders if he got the question
right: "What I?... am good at???"
Very often you get a nuanced and multifaceted
description even from people who are not used to thinking about such
things. Almost every time a friendly and relaxed atmosphere develops that
facilitates co-operation.
Be thorough with this question. Don't worry if the
client has difficulties answering. Ask what mother, father, lover, child
and wife would have answered if they were present. Ask about these peoples
attitude even if – and maybe even particularly if – the client has no
difficulties talking about his own resources and competence. The earlier
you start talking about the family in a positive way, the easier it will
be for you and the client to use their help in treatment.
Ask what the client used to be good at, and what he
thinks he can be good at in the future. Go for the future, the network and
life, and get that into the room with you and the client. If you have
difficulties in the present – use the future and the history. Take great
care in commenting strengths and resources, and if the client seems more
alert when talking about how a certain person sees things, ask more about
what that person would say if he or she was present.
That is talk about resources, competence, care and love
in the network.
Ask who cares, or rather:
"Who worries about you?"
"Who else?"
"In what ways have he/she/they tried to be of help?"
"Who will notice when it gets better?"
"How/what will they notice?"
"How/what will you notice on them when they have
noticed it?"
Ask how these people have been helpful before.
Following up these questions quickly inform you about
resources, competence and care in the network.
Don't accept "no-one cares". Ask what mother,
father, siblings and grandparents think about the situation.
If the addict answers that they do not know anything (which
often happens if this is the first question you ask in the interview), ask
what they think he is doing, and inquire in detail what he thinks they
think he is doing. Then ask in detail about his care and concern for his
family. Evidently he doesn't want to upset them by telling them he is
doing drugs or abusing alcohol.
"Don't you want to worry them unnecessarily?"
"Who will be most in despair when/if they find out?"
An alternative question is:
"If they knew about it, what would they think/say/do?"
Try reframing critical depictions of the network in
terms of: "So that is how they are trying to help you?"
"Dad is fighting with me all the time" —
"Aha, so he hasn't given up hope that he can make you understand".
Or: Mother is nagging all the time" — "Aha,
so she is working hard on trying to reach you?"
Possibilities to vary these reframes are indefinite,
and most addicts gladly accept alternative explanations for their parents
sometimes pushy behavior. Especially effective language seem to be:
"They haven't given up hope."
"They seem to stick it out despite all the crap
you did"
"They really must care very much as they haven't
thrown you out yet."
"So you haven't let them help you."
Once again; you and the client will most often be
spared of these difficulties if you start off by talking about what the
client and his family are good at.
If you have done the above first you wont have to ask
this question at all, as the answer will be obvious. At this point it may
be wise though to make it clear to the addict that you understand that he
is making efforts not to hurt the people he loves, even if it is obvious
that he is not always successful. Sometimes it suffices to say: "You
and your mother are really very close".
Sometimes more is required.
We’ve already talked about the miracle-question. Our
experience is that it is good to ask it in a special way and progressively
modify wording and intonation till it fits one’s personal style. One way
to frame the question that we think works for many therapists is "I
have a difficult question", look thoroughly at the client and check
that you have his attention. Continue with: "Suppose we sit here and
talk, and after this conversation you do what you ordinarily do and
tonight you go home and go to bed and you sleep. While you are sleeping a
miracle happens, and the problems that brought you here disappear. But
since you are asleep when the miracle happens you don't know it happened.
What is different (what do you do differently) tomorrow that will make you
and others believe a miracle happened?"
Acknowledge verbally and non-verbally descriptions
like: "I would have better self-esteem",
"I would be happy",
Then explore what the client means. The simplest way is
to wait calmly in an interested way – sometimes for one or several
minutes – and ask only: "What else?"
Then if necessary help the client to be concrete:
"How do other people see when your self-confidence is a little better?"
Some clients need more help: "What do you mean by
better self-confidence? Some clients I met would have meant that they
dared stand by the window when there is a thunderstorm instead of crawling
under the table. What do you mean?"
Reflect on the fact that labels signify different
things to different people, and that labels are simply a way to categorize
different behaviors under a common word like; depressed, anxious, unsure,
phobic, etc. It is always good to break these categorizations into the
parts that are specific for exactly this client. This is particularly
obvious when clients use words that are not exactly correct. A young man
seeks psychiatry because he is depressionated. What he means only
becomes clear when he describes what he is doing on the days that he is
not depressionated.
Variants of "the problem would be gone, and I
would be happy, in harmony, drug-free and very wealthy", are also
common first answers.
If "what else?" doesn't lead on to more
elaborate descriptions, follow up with: "Ok, so when you are happy,
harmonious, drug-free and very wealthy, what would you do differently? How
will other people notice by what you do tomorrow, without you telling them
that the miracle happened". Try to get concrete descriptions of daily
activities and situations.
Be extra curious at this point, as your curiosity will
help the client to be creative. Think about the fact that just imagining a
future without the problem is a process that changes people. Don't give up
easily. The descriptions you and the client will create are descriptions
that shows in what direction the client wants to develop.
If the client shrugs his shoulders, looks at you with
contempt and says: "I haven't got the slightest idea!!" Well,
maybe it’s time for you to make up your mind and decide that you haven't
succeeded this far to establish a relationship where the client is
prepared to say that he is willing to work hard to change his life and is
prepared to follow your advice. Content yourself with having as pleasant a
conversation as possible. Find out what the client is good at, and
terminate the session by giving compliments for that. If you do this in a
nice and respectful way, and perhaps adds that the client is showing
extraordinary strength by not letting himself be pulled into god knows
what crap, there is a chance that the client will want to come back. If so
it might be possible then to establish a relationship where the client
expresses that he wants to do something more, or at least says he has a
problem.
If the client answers that there are no miracles, or
something similar, you can answer: "You are right. There are no
miracles. There is only hard work, so what would be a sign tomorrow that
something is happening and that things are moving in the right direction,
that is the direction that’s right for you?"
Another alternative that works surprisingly often is:
"No there are no miracles, so pretend." Don't forget that
clients put a lot of effort into trying to co-operate with you and they
make efforts to answer even the weirdest questions. We have seen clients
answer the question: "Ok, so if you knew, what would you answer?"
It is very common for addicts to give very useful
answers to the miracle question and other future-oriented questions.
Answers that clearly show what they think they will do differently once
the problem is no longer a problem. Often it seems by the way to be
exactly those things the client need to do not to abuse whatever he or she
is abusing.
Conceive the miracle question and other future-oriented
questions as questions that orient about the goal and try and get
descriptions of these goals that fulfill the criteria for useful goals
(page *).
"I would be sober when I see the kids. I would
pass a liquor store with money in my pocket without going in. I would
answer no thank you when Nils asks me if I want a drink."
Agneta will wake up happy in the morning, go jogging
before breakfast, eat an ordinary breakfast and then go out and look for a
job.
Ingrid would take care of her kids in the morning. Make
breakfast, have fun with them, so they would go happily to school and
don't argue with each other all the time.
An indication that a miracle-answer is useful is if you
can use the same phrasing and ask if it ever happened.
"Does it ever happen that you jog before
breakfast?"
"Does it ever happen that you are sober when you
see your kids?"
"Does it ever happen that the kids go off to
school joyful and happy?"
Don't do this until later on in the interview though as
you and the client risk getting caught by the history instead of creating
the future.
A word of warning. The miracle-question is not a
miraculous question that solves any problems. It is only one way among
many to find out what the client thinks will be different when he no
longer needs treatment. For some clients it is as effective to ask: "What
do you think or believe will have to be different in your life for you and
others to think/feel that you don't have to come here anymore?" or
"How will you know that it has been helpful coming here?"
Always explore how other people will notice when
"the miracle happened" or "when the problem is solved or on
its way to be solved".
Start from the people you already talked about in your
questions:
"What will your mother/father/sister/wife/children
etc notice that is different?"
"How will you notice on them that they have seen
the change?"
"Will your children fight less with each other
when they are less worried about you?"
This part of the interview is particularly important
when the clients' attitude is characterized by the idea that other people
have to change for the client to change.
The purpose of developing is to explore and develop the
clients' options. Useful questions at this point are questions about
exceptions, pre-session change and scales.
These and the scaling-questions below are questions
that build on the miracle question and other goal-related questions. That
means: You should have paid attention and listened closely to the clients'
ideas about his future, so you weave in his ideas and phrasing in the
follow-up questions.
The client says that the morning after the miracle she
wakes up alert and joyful. Takes care of the children and jokes with them
so they go to school alert and happy.
After a number of "What else?" from the
therapist leading on to more complex and detailed descriptions of how the
children will behave differently towards each other and towards mother,
the therapist asks: "Does it ever happen that you joke with the kids
in the morning?"
"Last Friday," answers the client.
"Were they happy?"
"It was a huge difference. When I am in a good
mood and feels well in the morning, they don't fight with each other.
When clients answer relevant future oriented questions,
the answers will be related to the clients’ own experience and the
clients’ own ideas about what will be different when the goals are
attained.
The problem always exists in relation to something that
the client can perceive as an alternative. It is your responsibility to
ask questions that makes the client examine these alternatives.
Behaviors or events that we called exceptions can be
signs of "pre-session change" if they are relatively new.
The mother in the example above could have been asked:
"Last Friday when you woke up early and prepared breakfast for your
kids, is that something new since you decided to do something about the
problem and called to make an appointment?"
It is very common for addicts to come sober or
detoxified to the first session. It is quite natural to ask how they did
this: "How did you do it to come here sober/detoxed?"
Sometimes pre-session change can be rather dramatic or
can at least seem so.
Roger is 27 years old. He has abused amphetamines
rather frequently for many years and is in a detoxification unit since one
week. He has agreed to be interviewed by a consulting therapist (Steve de
Shazer) and comes to his first interview.
During the interview it appears that no one knew about
the addiction before, and that it is not until now that he told his wife,
his children, his parents and his employer.
Roger is very optimistic about his future. Ahead he
sees more closeness with his family and perhaps with everyone, as he
opened up to a lot of people and got a lot of positive response. He thinks
that when the problem is solved, he and his wife will help each other more
with the children, he will exercise more and he will devote more time to
his old interest in lightweight aircrafts.
Roger is very hopeful. He says his life changed when he
contacted the detox-unit and he is so grateful to be in treatment.
Someone in the group behind the one-way screen groans
loudly and exclaims: "He is so naive!"
The therapist and Roger together build concrete
descriptions around what will be different in the future and eventually
the therapist asks what of all this that is already happening a little
bit.
Roger then recounts that since he contacted the
detox-unit 6 weeks ago, almost everything already happened and he even
bought a building kit to construct a 2-seated airplane. He says he knows
exactly what he has to do to continue what he already started – someone
in the observation-team remarks that he looks surprised while saying it
– and he is more than 70% sure that he will succeed.
The session is terminated with compliments from the
therapist and the team over how far Roger already got and with a task. He
is to think about what he has to do to rise to 80% until the next visit in
2 week.
When Roger wanders back to the detox-unit he says to
the accompanying staff: "Damn it, that was a lean (smooth?)
bastard!!" The day after he unexpectedly discharges himself from the
unit.
2 weeks later he comes to his appointment, but when the
therapist comes to bring him in from the waiting room, he explains that he
only came to cancel his appointment. He doesn't need it because;
"that guy from America, when we talked. It was as if he put out rails
and now it's just straight ahead."
When you have looked at exceptions, pre-session change
and defined the goal it is often wise to sum up the situation in more
global terms.
Actual-situation-scale: "0 means the worst
situation ever and 10 means the day after the miracle. Where are you at
today?"
Confidence-scale: "10 means that you are 100%
confident that you will solve this problem and 0 means the opposite. Where
are you at today?"
Effort-scale or prepared-to-do-scale: "10 means
that you are prepared to do anything within your power to solve
this problem and 0 means that the only thing you are prepared to do is to
sit on your but and wait for a miracle. Where are you at today?"
"Hope-scale", "chance-scale",
"others-prepared-to-do-scale" and "close-to-goal-scale"
are other useful scales. Once you start using them you will find more.
If the client is low on confidence but seems to want to
do something about his problem, it can be wise to ask: "Who shall we
call in case you have a falling-out, and stop coming here because of
that?"
These are questions that fulfill at least two purposes.
First they help clarifying if the goals are concrete enough to be useful
to the client. Secondly you give the message that therapy will not be
eternal, and will end when the goals are attained.
"What do you think you will have to have achieved
to feel that you don't need any treatment anymore?"
"What do you think your mother/father etc will
have to see to think that you've gotten over this problem?"
"When can we quit?"
"What will you notice on them (nod or point to
other people present) when they think the problem is solved?"
With clients who have formed vague goals it is
important to remember answers to the different scales used. Changes on
these scales can sometimes be the only way to know if treatment is of any
use.
When ending a session we want to feed back our
understanding of what the client told us and we want to try and bring some
new perspective. We need the break to think about and discuss with our
team or ourselves what the client told us, but the break is also there
because we want the client to take seriously what we are saying.
"I would like to take a break to sum up how I see
your situation", or
"I would like to (usually) take a break to think
through how I understand what we have been talking about".
See pages * - *
about the summary and see Jon (page *)
for an example that fairly well describes an ordinary first session. |
