Succeeding with Difficult Clients: Applications of Cognitive Appraisal Therapy
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This shift in focus is often quite exciting for clients. They frequently report feeling less discouraged if they do not have to solve a problem but rather remain standing in the face of it. Paul decided that he would like to be able to listen to his highly critical supervisor's feedback rather than avoiding or arguing with him as he had done in the past. I can stand up and be the one to take it for my work group. Instead of thinking he was personally flawed, he would think of his work as being of poor video quality. He would try to make an adjustment in his work practices and see if it worked better.
Notice that Paul's resilience as a vlogger is used as a metaphor to help him creatively reframe his perspective on challenging experiences. Paul and his therapist devised a behavioural experiment to apply his PMR with his supervisor. Following good principles of behavioural experiments, Paul planned a specific experiment, made predictions about what would happen and wrote these down.
Instead of predicting what his supervisor will do or think if he stays and listens, Paul made predictions about his own resilience. How many minutes did he anticipate he could stay resilient in the face of criticism?
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What would resilience look and feel like? What would his thoughts and feelings be after the encounter with his supervisor if he stayed resilient? And, if he were unable to stay resilient during his encounter with his supervisor, Paul agreed to take a few minutes and review his PMR to see if additional strategies might have helped him stay resilient and remain in the situation longer.
Clients and therapists alike can be prone to think about experiments in terms of whether they lead to a preferred outcome. Paul, for example, hoped his supervisor would be less critical if Paul listened to him. It is important to evaluate resilience experiments in terms of resilience, rather than any other outcome. Observe how his therapist debriefs Paul's behavioural experiments through a resiliency lens.
Paul: complaining My supervisor was really rough on me this week. Therapist: Well, we wanted you to have a chance to practise being resilient. If things had gone smoothly… no chance to practise.
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Sounds like you had lots of opportunities to try out your PMR this week. Did you remember to use it? Therapist: Let's take those examples and see what you did to stay resilient debriefs the examples by using a resiliency lens: focusing on how long Paul stayed resilient, what strategies helped the most, how he felt etc. Therapist: Being resilient doesn't mean you'll be happy about what you are facing. It just means you are still standing at the end of the day.
Therapist: How might that be? Paul: I think, before, I thought I was in a battle with my supervisor. Either he came out on top or I did. And usually I ended up mouthing off and getting fired.
Cognitive behavioral therapy
But this resilience practice makes me think of it more like being on a bucking bull. I win if I just stay with him, even if I feel tossed around. At the end of the day I can feel good about myself because I didn't go off and shoot my mouth and lose my job. And I'm developing a kind of flexible toughness. Therapist: Flexible toughness. I like that. And staying on a bucking bull is a good image, too.
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You don't have to like being tossed around but it sounds like you feel sort of proud of yourself for hanging in there. Therapists can respond to clients in a playful way if experiments do lead to a reduction in adversity. Consider this exchange that occurred a few weeks later in Paul's therapy. Paul: This week was amazing. I was all ready to take in an earful. He actually shook my hand! Therapist: Oh, yeah. That's a good thing for you in your job. But it's going to take away our guaranteed opportunities to practise resilience every week.
Therapist: smiling We'll just have to hope we get lucky and some other areas of your life start getting rough. As shown in this dialogue, our resilience model encourages clients to use life difficulties as fodder for resilience practice. Once clients have experience using their PMR in planned experiments, therapy shifts to looking for spontaneous opportunities to practise resilience in everyday situations. And clients are encouraged to greet negative life events as opportunities to practise resilience. If things go well, they win. This perspective often enables clients to embrace challenges and can help them overcome avoidance.
Thus, resilience practise not only helps people manage life difficulties, it minimizes the number of life events that are experienced as aversive. Therapists often need to adopt new beliefs and behaviours when they shift to using CBT methods to construct or strengthen positive qualities such as resilience. Further, our resilience model posits that the strengths necessary for resilience can be found within recurring activities. Thus, therapists are encouraged to actively search for strengths and the components necessary to build resilience within the client's common daily experiences. CBT therapists who are working to build positive qualities will find it helpful to smile more than is typical in therapy to a encourage client creativity and b communicate to clients that discussions of strengths and positive aspirations are welcomed and valued by the therapist.
Therapeutic silence is also important. Creative processes benefit from time to think. When a client is asked to imagine how they might use their PMR in a challenging situation, the therapist is advised to maintain silence with a slight smile on his or her face to convey confidence that the client can succeed in thinking of something. Evocation of positive imagery and metaphors is emphasized in our approach. Thus, it seems likely that the use of imagery can strengthen the likelihood of enacting positive qualities in one's life.
In our clinical experience, imagery and metaphors also help clients construct novel applications of their PMR, as illustrated above when Paul imagined himself as a disc jockey. Behavioural experiments are set up to test the utility of a PMR rather than to evaluate particular beliefs. Guided discovery is used to construct new ideas rather than to dissect existing beliefs; this entails the use of constructive language and constructive questioning approaches.
Although our model can stand alone as an approach to help people who wish to become more resilient, it is not intended to replace classic CBT approaches for treating depression, anxiety disorders and other problems. That model is different from our own but has the current advantage of some empirical support. In addition, we encourage researchers to empirically evaluate our assertions regarding the benefits of the modifications in the therapeutic frame advocated above.
It posits that there are many pathways to positive qualities and that each person can construct a personal model to build a desired quality, drawing on strengths already in evidence. The first step of our approach is a search for hidden strengths within everyday experiences. Second, existing strengths are used to construct a PMR. Third, the therapist asks the client to use the PMR to devise a plan for increasing resilience in an area of life where the client is currently struggling.
Fourth, the client practises resilience through behavioural experiments that are debriefed with a focus on resilience. In those cases, the search for hidden strengths explores areas of the client's life in which the client is already likely to exhibit the desired quality. Identified strengths are then used to construct a personal model for developing that quality more fully throughout the client's life. Behavioural experiments are designed to test the utility of the personal model and the client continues to practise the new quality until it is strengthened to the desired degree.
Knowledge of research cf. Volume 19 , Issue 4. The full text of this article hosted at iucr. She is listed in Who's Who in America and most recently she authored the final chapter in Howard Stern's best-selling book, Private Parts.
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Sheenah is regularly quoted in magazines, especially Allure, Elle, Mademoiselle, Redbook and Newsweek. She has been a regular panelist on "Geraldo. Jonathon Stern, Ph. In addition to working with adults, he specializes in psychotherapy with teenagers, children and their parents. He received his undergraduate degree in Psychology and Spanish from Haverford College, his doctorate in clinical psychology from The University of Connecticut, and completed an internship and an advanced internship in child forensic psychology at Children's Hospital in Boston.
He has published articles and chapters on doing psychotherapy with difficult parents, has given numerous training workshops to professionals, most notably at The Society for the Exploration of Psychotherapy Integration, and has taught at Pace University, Marymount Manhattan College and The University of Connecticut. We are always looking for ways to improve customer experience on Elsevier. We would like to ask you for a moment of your time to fill in a short questionnaire, at the end of your visit.