- [Dr. Drisko] We are very pleased this year to have
Dr. Elizabeth King Keenan
who is a professor at Southern Connecticut State
in New Haven, Connecticut.
She holds an MSW degree
from Loyola University of Chicago,
and a Ph.D from
the Smith College School for Social Work.
Dr. Keenan has worked as a practitioner,
and has also served as an adjunct
faculty member here at Smith
for the New York University School of Social Work,
and for Fairfield University.
One of her innovations
at Southern Connecticut
has been to help develop approaches
to support her faculty with heavy teaching loads
to also be productive scholars.
She's been successful in this effort,
and earned the gratitude of her colleagues,
and also the profession.
She was a speaker two years ago at the group
for the Advancement of Doctoral Education
speaking on just this topic.
In her own scholarship Dr. Keenan
has been recently the co-editor with
Melissa Grady of a special issue
of Clinical Social Work Journal entitled:
"Beyond the Manual: Using Research
"and Evidence in Clinical Social Work Practice."
This issue is now out electronically,
and is due out quite soon in print.
With her colleague Mark Cameron,
Dr. Keenan is the author of a book entitled:
"The Common Factors Model
"for Generalist Practice"
just published by Pearson in 2012.
She's the author of many journal articles,
and notable in this area is an article entitled:
"The Common Factors Model:
"Implications for Trans-theoretical Clinical
"Social Work Practice"
which she authored with Dr. Cameron,
and was published in social work.
Also, another article that I like a lot,
and I really like the title called:
"From bumps in the road to the edge of chaos:
"The nature of change in adults."
This was published in
the International Social Work Journal in 2001.
We are very fortunate tonight to have with us
Dr. Keenan who is a talented clinician,
educator, and scholar,
and we're happy to have her with us
as the Brown Foundation lecturer for 2014.
Dr. Elizabeth Keenan.
(applause)
- Thank you Dr. Drisko, thanks everybody.
Tonight I'm going to be using
a few case examples from various students
that I've been working with and learning with,
and I want to extend my gratitude to them
as well as to all the students and colleagues
and supervisees who use various versions
of this work while it was in process.
So after working as a music director
for several years, I decided to go back,
and get my MSW in my late 20's.
I wanted to get to know the stories behind
the weddings, and the baptisms, and the funerals,
and the hundreds of couples and families
that I had only briefly met when I talked with them
about what music they wanted for these events.
I wanted in depth conversations.
I was hungry to hear the backstory.
I wanted challenges, and I got it.
At Loyola University of Chicago
I learned about psychodynamic theory.
At my internship I learned how to create
therapeutic relationships,
and track clinical process with adults,
and in my other internship with children
in a school setting
I learned how to create a holding environment
in the only space available
in the basement next to the heating pipes.
Quite a challenge.
But my practice experience after graduation,
however, left me feeling pretty perplexed.
I faced quandaries,
and so many moments of uncertainty.
I was working with families and individuals
from preschool age to elders,
and encountering what felt like at least half
of the diagnoses from the DSM,
as well as a range of trauma and grief reactions
from family and community violence
in neighborhoods while I worked
at a Community Mental Health Center,
a Family Service Agency,
and a Town Counseling Center.
So what could I use to guide my practice,
and how could I possibly become proficient
with all the practice models
that were being created for
a range of people I worked with.
I went on a quest attending numerous
continuing ed seminars,
and reading just about anything
I could get my hands on
searching for ways to deal with this uncertainty.
This quest led me to the Ph.D
program here at Smith.
I started to find my footing again
as I learned about decades of research
that examined many of these same dilemmas
as well as clinicians who were trying
to craft innovative responses.
So before we continue
I invite you to take a moment,
turn to someone next to you,
and just share what is it
that anchors your practice.
What guides your thinking?
So take a minute and talk that out with someone.
(chatter)
Okay, can I invite you to come back
to the larger room.
It's great to hear your energy out there.
Now I feel like we're all ready to go, all right.
So as we move on
we start thinking about what is
the story of us as social workers.
We've talked about our dilemmas,
what anchors us,
and throughout the history of our profession
we have encountered these
dilemmas and challenges.
In the first several decades of our history
there were a few primary theories
that were developed.
Psycho-dynamic, behavioral, cognitive,
functional, humanism,
and then family and group models,
and each new theory is a response to a gap
that was not being met,
or was perceived to be there
from previous models.
So then research on psychotherapy,
and various models also started to take place
starting in the 20's.
Research has looked at these theoretical models
in three different ways.
So first of all overall efficacy and effectiveness.
So when we're looking at efficacy
what we're thinking about is internal validity.
Does it work under certain conditions,
and effectiveness, external validity.
Can I use this model with another group of people
in a different setting,
in a community setting, for example.
So we have over 50 years of research
with thousands of studies,
and has generated evidence that psychotherapy,
yes, is helpful, and it does help
clients make meaningful changes.
Then we have comparative effectiveness studies
that look at different practice
models with each other.
Rosenzweig, in 1936 was the first to pause
at the hypothesis that in general
no one model really is superior to others,
and he quoted the Dodo bird from
"Alice in Wonderland" who said:
"Everybody has won and all must have prizes."
Since that time research still finds little,
or no substantial difference between therapies,
and what we mean by this is:
Similar numbers of clients do improve
across different kinds of treatments.
Then, finally, we have process outcome research,
and that seeks to identify and understand
what are the factors that influence change,
how do they interact.
We've been identifying several factors,
and then calling them into question ever since.
So when learning about these
different bodies of research
I was excited to learn some of the things
that I had paid attention to like the relationship,
the clinical process,
were being examined in research.
I was still troubled, though,
because some of the groups that I worked with
remained underrepresented in this research.
That includes LBGT youth and adults,
various racial and ethnic groups,
and people who are experiencing
multiple psychosocial problems.
I was also troubled because many people
still are not helped by psychotherapy.
Some drop out prematurely,
and some do not benefit,
so clearly more work needs to be done.
So since I finished my Ph.D in 2001
more work has been done.
People have been generating numerous amounts
of additional practice models
for some of the populations
that I mentioned that were being marginalized,
or not thought about,
but also innovative different models.
So from good therapy that had to work
what you see here is just the practice models
beginning with the letter "I."
There are hundreds of them, go look.
In addition, those who pay for services
are asking for increased accountability by us.
They're asking us to use models that work,
and they're asking us to demonstrate
that what we do is effective.
So this push for accountability
has led to more research on what is being done,
and there are several sites
that publish some of the work,
and three of them are here on the slide.
For example, SAMHSA lists
335 programs and practices
in their national registry of evidence-based
programs and practices.
Yet, despite all of these new models and research
we have choices, we have more challenges.
I'll highlight four.
How do clinicians in organizations select from,
for example, these 335 programs and practices
especially in the face of budget cuts,
and constraints for resources.
So we know evidence-based practice, EBP,
is a process that helps guide the selection,
and make these decisions,
but the process itself requires skills,
time, and resources that are hard to come across
at organizations that address multiple kinds
of psychosocial problems and disorders.
Next, EBP says to make decisions using
the integration of the best research evidence
with clinical expertise and client values.
So if a client's beliefs are not consistent
with a practice model that has strong evidence
what do you do?
How do you use your expertise in ways
that respond to the clients
preferred ways of working?
Or three, what do you when specific
client attributes, or combinations of problems
don't fit a model that has empirical support.
Do you adapt the model?
We have implementation science
that's beginning to do that,
but how do we know if we're adapting it,
and then leaving out an ingredient that is
a key ingredient that affects change.
And, finally, we still have some competing,
and conflicting research evidence,
and an example of that is, again,
from the SAMHSA website.
It says: "Decades of careful scientific research
"indicates that psychotherapy success
"is influenced by ... "
Well, you can see it,
just about everything, right?
However, the therapy relationship
accounts for why clients improve,
or fail to improve as much as
the particular treatment method.
SAMHSA believes these research findings
may compliment and/or augment the information
contained in those 335 intervention summaries.
Okay, but what does compliment,
or augment mean in practice?
How does one do that?
How do you put that together?
So, more confusion.
More information, more confusion.
I was still a little stuck trying to
figure out what to do
so I started having conversations
with my colleague Mark Cameron.
He and I decided it was time to find a third way.
A model of change that looked at relationship,
and method together,
not in complimentary ways,
but in an effective, workable practice framework.
Our thinking was to create a model
that could be used as the default mode.
The what we always do mode
that could serve as a scaffolding
for specific treatments.
So we started putting together this model
by looking at the empirical evidence
for what's in common across models.
Michael Lambert is someone who has helped
provide various categories
identifying what might be in common,
and he came up with four categories.
The therapist techniques, expectancy,
the belief or hope that change can happen,
relationship factors,
and then client and environment factors,
or what he called "extra therapeutic."
So let's stop for a minute.
If we think about the influence
of all four of these factors
totaling up to 100%
which one of these do you think
has the greatest amount of influence
on outcome variance?
Which one would have the greatest influence?
What percentage would you put to it?
So take a minute and think about that,
and then I'll show you what Lambert said.
Ready? Okay, here we go.
So the client factors
have the largest influence score
in the back there, excellent.
Followed by common factors,
and the key thing that we learn is that
therapist techniques have only
a small influence on outcomes.
So in looking at this literature we knew
that we needed to include not just techniques,
and relationship factors,
but we had to look at other factors as well.
So we kept exploring, and next we turn to
Grinkevich and Norcross,
and they reviewed 50 publications to identify
commonalities across therapeutic common factors.
Client therapist and relationship factors,
and here's something interesting
where they start to diverge from Lambert.
They came up with a category called "processes"
that produced positive outcomes.
So this is not techniques, but processes,
transtheoretical means,
and we'll get into what that means a little bit later,
but I just want to draw your attention to that.
So we had the beginnings
of some ideas for a model.
Client processes, therapists,
but we still hadn't figured out what to do
with those areas in red.
Social and material supports,
organization and professional helping system.
We wanted and knew we needed to include
something about these extra therapeutic factors
because we are social workers,
and we know how much the environment,
and the interaction between key people
in client's lives affects what happens
to a person's well being,
and it also felt important because
we knew we needed to take a look
at the issue of power.
Not just relational power as a healing,
or curative factor,
but also power as its exercised
within, and between groups of people,
within organizations, within communities.
So, thankfully, we have Dr. Drisko
who provided us some language
to flush out these extra
therapeutic factors of Lambert.
So Dr. Drisko brought
the person in environment perspective,
the lens to Lambert's conceptualization,
and he helped identify policy and agency context
of the therapist as well as
aspects of the client context and client attributes.
So we were ready now to construct our list.
So Dr. Cameron and I renamed
a couple of the categories.
We put our list together.
And we then began to conceptualize things
as an ecology of conditions and processes.
So as we switch here
I just want to emphasize this one piece.
A list is fine, but a list doesn't guide practice.
A list doesn't help us know
what to do in the moment,
so we had to back up once again and say:
"What is our understanding
"of how change occurs in therapy,
"how change occurs in social work practice."
So more and more evidence suggests
that it is not a linear way,
it's not a linear path of the medical model,
but rather research suggests,
and we know from our clinical experience
that change in psychosocial functioning
occurs through dynamic interactions
of multiple contributing factors.
So none of these factors operate alone,
and no one factor
is the one factor that causes change.
Rather, they are in a constant flux
of interaction and interdependence.
Now we're getting a little abstract here
so we need to switch things up a little bit,
and try and see if we can't get
a feel for what's going on here.
So let's switch into a gardening kind of mode.
How many are gardeners?
Flowers, vegetables, fruit?
Excellent, okay.
Me, not so much.
I like the indoor plants
I can water once a week,
and they kind of survive, you know,
they like a little light and we're good.
Nonetheless, I've watched a lot of people garden,
and here's what I've noticed.
So you get your seeds,
and you got to pick the soil,
and you need to find the right kind of light,
and the right climate.
If you're outdoors, not too hot, not too cold,
and you plant things,
and you hope that you don't have a freeze
like we did when we planted sunflower seeds,
and nothing came up,
but you also have to be paying
attention to the pacing.
So if all of a sudden it's 80 degrees in June,
and that's not working for your plants,
then they're gonna get a little burnt,
maybe a little droopy.
So the key thing here is that
you've got conditions of soil,
and temperature,
and rain, and light,
but they need to interact with the seed itself
in particular kinds of ways,
and at the right timing and pacing.
So let's switch now to Winnicott,
and a holding environment, right?
So if the seeds are the metaphors for clients,
the soil and the terrain is some of what
the therapist uses as a holding environment.
It's the therapists social network.
Where are you meeting?
How supportive is it?
What are all the procedures,
and the paperwork, and the documentation,
and the reimbursement,
and are you feeling welcomed.
Then the rain and the sun and the shade
are the other aspects,
the activities that we provide,
efforts to listen, acceptance, empathy,
and then we pay attention to
how well can the seed,
how well can the client take it in.
Can the person experience it?
Are they ready, are they at a point
that the client is able to engage with it.
So when Dr. Cameron and I conceptualized
how these factors produce change
we noticed that these factors functioned differently.
Some were conditions,
others are processes.
And that we knew that an ecological model
of them interdependently interacting
is where we wanted to go.
So I'm gonna move through a couple
of these things pretty quickly here.
Conditions are essential qualities or attributes
necessary for change and here's a list:
We have individual and family conditions.
There's you see, the expectation, the hope.
Social worker conditions.
Our empathy, our acceptance.
Social network conditions,
those policies and funding procedures.
We have processes that are activities
carried out by one or more participants.
We have relationship processes,
engagement, collaboration,
productive communication,
mutual agreement on what we're about
as well as change strategies.
And here's the interaction.
So the change strategies,
and relationship processes
help to enhance or establish conditions,
interact with them and produce
successful outcomes.
So now let's bring it to the ground,
and start talking about a case example.
So Kristen is a white female intern
of mixed northern European descent
in her mid 20's.
Her client Lily is a 17-year-old bi-racial female,
Japanese and Caucasian
currently living with her father
in an urban area in Connecticut.
Early childhood information is a big vague,
but Kristen knows that Lily's mother
abandoned her at a young age.
Lily lived for a few years with her dad,
but he became either unwilling,
or unable to care for her
at which point she went to live
with her father's sister, her aunt,
until her aunt's friend raped her one year ago
resulting in child protective service involvement.
The father asked that Lily be reunited with him,
and after a home study full custody was awarded,
but the father still remains largely unavailable
working 12 to 16 hour shifts at a factory.
Lily works at a restaurant in addition
to attending school.
She's tested at the above average level,
and is placed in AP courses.
She does not put forth much effort though,
and has pretty poor attendance.
From what Kristen could gather
Lily's aunt tried to play the role
of a nurturing parent,
but also verbally abused her,
and did not protect Lily
from being raped by the aunt's friend.
Kristen began to surmise that
this love/hurt combination
might feel normal to Lily,
and might be expected
giver her history of abuse,
and neglect, and instability.
In addition, Lily seems to be replicating
these dynamics with recent boyfriends.
She says she's attracted to drama
seeking men who are a bit older than her
who are verbally abusive towards her,
and cheat on her.
So using a common factors model
we're assessing not just the presenting problems,
and the psychosocial history,
but we're also listening for capacity.
We look for the degree to which we have
what it takes for something new to happen.
What conditions are available to work with.
What's missing or insufficiently present
that needs to be cultivated for change to occur.
Because if change happens with complex
interdependent interactions
we need to make sure that those factors
are there for it to take place.
So do we have what it takes?
If a condition is insufficiently present
we then think about is it going to interfere
with us taking a step forward?
Do we need to focus on maybe not the beginning,
but as the work continues,
and here's those conditions to assess again.
So openness of the therapist.
Kristen initially felt acceptance,
genuineness, and empathy.
Looking at the client factors,
Lily was experiencing a great deal
of emotional distress.
She was willing to meet,
and actively participating with Kristen,
but she lacked hope and really had
little expectation that change could happen
that would be any different
from the unpredictable change
that was out of her control.
When we look at the client's social network
no one seemed to be interfering
with Lily's participation and counseling,
but Lily did not appear to have any significant
relationship that was consistently caring,
nor any close friends at the school.
From the intern, the social worker perspective,
Kristen was providing these services
at the Student Assistance Center
in the high school,
and they also had other services
such as peer mediation,
and groups on various issues,
and the supervisor provided supervision
for all of the interns.
There was no worry about external funding,
and you get to see the student
in the educational environment.
So to summarize the conditions,
Lily was willing to meet with Kristen.
She was distressed,
but wasn't expecting
that anything could be different.
She lacked hope.
She also lacked social supports.
So Kristen noted that she wanted
to pay attention and monitor these conditions.
She wanted to see whether Lily
would really continue to come to meet with her
despite her lack of hope,
how much of that would affect her participation.
And she also wanted to listen for
how Lily would view Kristen
given her history of abandonment,
and recent trauma by caregivers.
How might transference themes
enter into the work.
So that takes us now to relationship processes,
or are we working well together?
So with the relationship processes
not just engagement,
but monitoring the communication
throughout the work,
having a mutual agreement, and collaboration.
So Lily was engaging with Kristen.
She was sharing lots of details
about past abandonments and abuse,
and recent verbal abuse by a boyfriend,
and she was doing it with
a great deal of emotional intensity,
but also a sense of this is just the way it is.
I'm upset about it and this is my life.
So given Lily's history of a lack of responsiveness.
and attunement by her caregivers
Kristen took Lily's lead for the initial agreement.
Lily said what she really wanted to do was
make sure that she graduated from high school.
That was her priority,
so Kristen went along with that,
and hoped that focusing on the goal
might help her to attend school more regularly,
and also support the intellectual capacity she had.
So what's the therapists role in all this?
A clinician's role is to facilitate this complex
interaction of conditions and processes
in the four ways that are up on the screen.
Having this initial and ongoing assessment,
making strategic judgments,
facilitating collaborative agreements,
and routinely monitoring and evaluating
the process and the outcome,
and you do it with the facilitation method,
a very simple thing of listening
reflecting on what you've heard,
strategizing, responding,
and evaluating how it goes.
So when things are going well
this facilitation method happens
largely out of our awareness.
When we really want to use it
is when we are getting stuck,
or not sure of what to say,
or we're caught off guard.
We listen for and we evaluate
how well things are interacting,
but it's not what do I say,
or what's the perfect response,
it's more what am I thinking
about how these factors are interacting,
and what am I thinking would be key
to help encourage as a next step.
So we do this moment-by-moment,
as well as with broad case conceptualization.
So back to Kristen.
Kristen's initial thinking was to focus
on a client condition.
Lily's lack of belief and hope
that things could be different in her life.
Kristen began to realize that not only
did Lily have a belief that change could happen
she seemed drawn to keep things
as familiar as possible.
With this in mind Kristen says:
"I started to explore to see if Lily
"could identify something she might want
"to reach for or work towards.
"She started to talk about going to Yale
"to be a pediatrician.
"I thought I could use this as an incentive,
"a kind of carrot.
"I was calling over to Yale,
"and working with my supervisor
"to try and organize a field trip.
"As the weeks went on, though,
"Kristen started to feel an internal pressure
"to help Lily achieve to be the adult
"who wouldn't be like the other adults.
"Kristen reflected on what
"she was sensing internally,
"and what she noticed
"in Lily's communication with her.
"I saw that my efforts really weren't effective.
"Seeing Lily's reactions I began to think
"that just like a nurturing relationship is frightful,
"so is a nurturing and positive life maybe.
"It could be that thinking about a successful life
"is almost too much to handle,
"and just as much of a trigger.
"Kristen reflected and worked on her
"countertransference reactions,
"her desire to have Lily make it.
"She started to strategize ideas
"for a different, mutual agreement
"that matched where Lily was.
"A place where she could help Lily experience
"support and understanding
"for what she needed to discuss,
"mostly the abandonment's and the abuse,
"and her recent trauma.
"Kristen reformulated her thinking
"that helping Lily experience
"a sense of feeling felt
"could be the first step
"towards a new experience of a secure base
"that might help her finish high school.
"Kristen reflected more on the themes
"of Lily's communications.
Lily would acutely feel a need to do something,
but not have the ability to do it consistently.
Lily's desire was reawakening
with this relationship with Kristen,
but all too often that desire had been crushed.
Her hopes had been dashed
most recently with her aunt and her boyfriends.
So using the facilitation method
helped Kristen in this moment notice,
and reflect on her countertransference reactions
that were interfering
with her empathy and acceptance,
and also interfering with her ability
to listen more deeply to Lily's communications,
and not just the literal communication
of what she was saying.
She began to understand Lily's motivation
more differently.
So using the facilitation method
helps a therapist's attention
go to where it needs to.
It guides thinking, zooming in and out
from assessment understanding
to specific moment to clinical process
looking to see if there are specific conditions,
or relationship processes that need tending
kind of like Freud's evenly hovering attention
except this time we're including
a broader, sociocultural, social network factors,
and not just the client's material.
So I want to shift now to an example
of the need to focus in on
some of the social network factors.
Efrain is a Latino in his 30's.
He's interning at an Elder Care Community.
He prefers to use his nickname "E."
so that's how I will refer to him.
E. focused on problems with
notification procedures between
various departments and staff
at this Elder Care Community.
He decided to work on the problem himself first,
and then take ideas for broader
organizational change to his supervisor.
E. says: "I first try to communicate with at least
"one person in each department.
"Housekeeping, laundry, dietary, maintenance,
"director of nursing.
"After chatting a bit I would ask something like:
"Hi, are you aware of a room change?
"I found out that many times
"staff were not aware.
"I then decided to attend the morning meetings
"where all units get discussed
"by the administration department
"with representatives from each
"of the other departments.
"I quickly learned who had what roles,
"and how much power and control they had,
"or at least how far the power could extend itself.
"The administration department
"would say things like:
"Assisted living has 43 occupancies,
"three vacancies due to medical illness,
"and one discharge to
"the Alzheimer's and Dementia Unit.
"The admin department decides
"which patient is moving where,
"monitors whose left the facility,
"and whose shifting units.
"The administration department rep
"would say things like:
"I've already spoken to the family,
"and the resident about moving
"to the Alzheimer's and Dementia Unit.
"Unfortunately, she's been falling down a lot,
"and can't remember where the room is.
"She's unable to maintain
"her activities of daily living.
"The family's in agreement with the room change,
"and Ms. M. understands we would be able
"to keep a closer eye on her.
"She'll be moving today.
"We are looking at Room ABC
"by the window with Ms. K.
"I also have someone coming in tomorrow
"around two who's going to be going
"into Miss M.'s old room.
"The admin department was calling the shots
"with only minimal input
"from other department heads.
"E. says because I had taken the time
"to get to know workers in different departments
"I knew that some wouldn't
"know about these changes.
"Even though decisions
"were being made at meetings
"staff who had less training and authority,
"but ultimately the responsibility
"for preparing rooms for residents
"were often the last to hear about these decisions.
"So I went to the unit to see how prepared
"they were with the room change.
"I knew Ms. K. was not going to be happy
"about Ms. M. coming into her room.
"On this occasion the charge nurse was aware,
"but the staff was not.
"The staff member was surprised and said:
"I wish somebody would have told me about this.
"I don't like being caught off guard,
"so I guess I'm gonna stay around
"because I want to get things ready."
So E. continues: "My goal was to increase
"the collaboration between the departments
"to make sure that the procedures were supported.
"It's unsettling for a resident
"when the arrival of the resident
"appears to be a surprise.
"Most people don't like surprises.
"They like to be prepared and have a unified front.
"This also gives the resident a sense of comfort
"that they will be cared for there.
"It's unsettling for a resident to hear someone say:
"I didn't know you were coming over here.
"This is their home, it's all they have
"at this point in their lives."
So we've talked so far about various conditions,
and relationship processes,
and how a clinical social worker uses
the facilitation method
to guide thinking and actions,
but now let's focus on how to decide
what work is optimal now
at any given point in the work.
So first we've already noted
that we're looking our conditions present or not,
and the first two examples highlighted
the need to cultivate specific conditions,
but now let's say they are,
and your relationship is developing.
So then what you want to think about is
whether you won't need and want to focus
on internal or external actions.
Internal actions are the things
that we're familiar with about insight,
and awareness, understanding,
emotional learning.
External actions focus on trying out new things.
Can I interact differently with my partner?
Can I parent my child?
Can I experience being a parent in a different way
as I'm going with my child to the park, for example.
So the focus of the work
shifts throughout the work.
You move around.
The top half is focusing on these conditions,
client, therapist, social network.
The bottom half is where clients begin to have
these new experiences
through the focus on internal and external actions.
Those aha moments.
Those moments where things feel different.
"Oh, well it used to be,
"or I used to do, but now."
Those kinds of phrases are examples
of when a client has made a shift,
and moved into a new experience.
And you do this work with the change strategies.
So they're organized into three categories.
The ones on the top left are strategies
that tend to happen throughout the work
no matter what we're focusing on.
The ones in the middle group are ones
that generally target internal action,
and the ones on the bottom right
target external action.
Now let's see what some researchers are saying
about changed strategies.
There seems to be another set of common factors
that reflects the complexity
of the process of change.
So these are those meta level
transtheoretical processes,
and at the bottom of the slide you see
that the research is challenging
the false dichotomy
that we've tended to have in the field
that technical interventions
are unique to specific approaches,
and that common factors are interpersonal,
and auxiliary to techniques,
or that complimentary or augmenting thing
that SAMHSA would say.
So what do we do?
We know about processes,
and we need to figure out
how to respond in the moment.
So here's where some of
the specific models come into play
because there's many ways
to enact a process.
We have lots of skills,
we have lots of techniques,
and what can be helpful is to think about
the various techniques that you use,
how would they connect up with a process,
but the key thing here is not so much
the what do I say,
but paying attention to how the client,
or family is experiencing,
and participating in these processes,
and that's where we look at the clinical process
at the moment-by-moment interaction
for evidence about how it is working.
So let's get specific.
One example of a process or change process
is interpersonal learning.
So here are four possible ways
that you might want to enact this process.
You can directly talk about
how a client is experiencing you.
You can talk with a client about
a relationship that they have with someone else.
You can talk about their expectations
for what they might see.
You can provide particular psycho-educational
knowledge about relationships,
and we see a lot of that in parenting groups,
or social skills groups.
So let's return, again, to Kristen and Lily,
and see how Kristen was facilitating
some interpersonal learning.
She realized that Lily was not ready,
or able to work on changing
her behaviors just yet.
And Kristen also started noticing some patterns.
Every week Lily would come and there would be
yet more distress in her life.
Kristen says: "I would constantly hear her say
"my life is so dramatic, I attract drama.
"So I asked her to think about
"do you think your life is really dramatic,
"or do you think that you create
"some drama in your life?
"Because I wanted to just test out,
"and see whether she could reflect on
"whether it was something
"that she thought could be changed
"realizing that what was familiar would also be
"pretty anxiety provoking that these were
"intense reactions she was having."
Well, Kristen says: "She got her answer.
"Lily said that she feels comfortable and safe
"with the drama in her life.
"She knows what to expect."
So Kristen said: "That queued me into
"the level of anxiety she was feeling
"that Lily was likely fearful that the next step
"of that relationship was abandonment or harm
"given what she had previously experienced.
"Kristen redoubled her efforts to focus
"on providing consistent care and acceptance
"along with some information to just let Lily know
"that sometimes drama can feel better
"than that uncertainty
"where you're waiting for the other shoe to drop.
"Kristen was listening to see if Lily was able
"to begin to develop a little bit of trust
"in this new experience with her.
"In addition to that Kristen also had
"Lily focus on other relationships in her life."
Kristen says: "I remember her talking
"about her aunt.
"It was a very conflicted relationship
"because I could hear the animosity,
"and the resentment in Lily's voice,
"and also hear her passion and love.
"I listened and tried to be a sounding board.
"Lily wanted to tell me about everything.
"This process helped her begin to reflect
"on what she had experienced,
"and started questioning little bits of it.
"I remember her saying things like:
"How could she do that to me if she loved me?
"One particular session she just wanted
"to talk about her mother.
"She was very emotional and explained how
"she wanted to get to know her.
"She didn't know why her mom
"had abandoned her.
"She felt a lot of shame.
"It was clear that Lily's desire to understand
"was a deep need to try to appreciate
"whether she had some part in it
"that she was feeling
"a sense of badness about herself."
Kristen says: "For whatever reason
"her mom did abandon her.
"Lily might end up tracking her down,
"or talking to a relative,
"or maybe never finding out what happened.
"What's important now is to see if Lily can consider
"that it might not be her fault,
"that she might not be bad
"because her mom abandoned her."
So just to reiterate that the strategies,
these change processes,
are organized in terms of what we want to facilitate
what we want to have clients
experience throughout the work.
One's that focus more on internal actions
like what I just said as well as external actions.
So with Kristen and Lily
Kristen started with motivation
concerned about the lack of hope that Lily had.
She then noted the need to address
her own countertransference reactions
that were interfering with her empathy,
and then she shifted into areas of developing
resources through the relationship
of Kristen and Lily
as well as working on interpersonal learning.
So as you're going through the work
the facilitation method
is what one uses in the moment
when one is stuck and guides your thinking,
but now let's talk for a couple of minutes
about who you work with.
So, yes, individuals and family clients,
or groups of clients is a common decision,
but we also seek out professionals,
or para-professionals who are also
influencing the work.
So here's an example of that.
Steven, an Italian American male
in his mid 20's is interning at an
Early Childhood Development Center.
Steven says: "Paul Kivel poses this question.
"Are you willing to speak truth to power
"even at the risk of your job by certain agencies?"
Steven says: "I wanted to report two teachers
"that were negatively treating a child
"just about everyday the child
"was there at the center.
"They would pick on him, make fun of him,
"and make him susceptible to teasing
"due to the nature of their discipline strategies.
"The risk that I ended up taking
"was talking with the director
"about the teacher's behaviors.
"This was still challenging
"because the director was barely involved
"with what was going on in the classrooms.
"Instead of angerly pointing out to the director
"that she was not doing her job,
"which is what I wanted to say,
"I talked to her about what I had observed
"hoping that this would motivate her
"to become more involved.
"I respectfully asked that
"she come spend some time in these classrooms
"just to get a feel for what was going on,
"and understand better.
"She hesitantly obliged and did set up the times.
"After sitting in on the classrooms
"the director asked my supervisor and I
"to respond by working with the teachers.
"Apparently the risk I took by asking her
"to take some time to spend in the classrooms
"paid off and it did raise her awareness.
"She said she wanted the children to be able
"to learn from their mistakes,
"not just to be disciplined.
"So my supervisor and I set about
"to schedule times with the teachers
"where we could have them share
"their concerns and frustrations,
"but then also say that we had some
"additional ideas that we thought might be useful,
"and might make it a little bit easier
"on the stress that they were feeling.
"We wanted to convey to the teachers
"that we were on their side.
"We wanted to hear their needs,
"and that we had ideas that might be helpful
"to them as well as to the students.
"In subsequent meetings we discussed ways
"that positive reinforcement strategies
"could be instituted with the children
"in their classrooms.
"The actions worked.
"My supervisor and I gave them tools.
"In turn, it provided more support for the teachers,
"and the students were able to learn
"from what was going on in the classrooms.
"It was a big risk for me to take
"to speak with the director
"because of her position of power.
"I was hesitant, but with my supervisor's support
"it felt great to find a way to interact
"that engaged the director
"that really turned around the way
"that the development center was functioning."
So with the ongoing work then
you are going to shift back and forth
noticing about whether you need to circle back
if someone begins to get discouraged,
and feeling a little bit down
about the lack of progress with the work.
If you need to work on some of your own reactions.
If you're noticing barriers within your organization
that need to have a response.
And, again, the focus of the work
shifts back and forth around in these areas.
So last piece on Kristen and Lily.
Despite missing 90 days of school during the year
Lily would consistently come to school
on the days that she had
her appointments with Kristen.
Kristen says:
"That after Lily was attending
"weekly sessions for five months
"she decided to try an alternative school
"so she was out of this school for a month.
"Lily ended up coming back
"one month before Kristen ended her internship.
"The first day that Lily came back
"she came right to Kristen's office,
"and Kristen hoped it meant that she had
"experienced a little bit of caring,
"and felt that it was real for her,
"but at the same time Lily was still having trouble
"focusing on school.
"As we wrapped up our work Lily said
"her main goal was to get
"her high school diploma next year,
"but it was still hard for her
"to make it to school everyday.
"Things felt so tenuous.
"One step forward, two steps back.
"Kristen was concerned that
"the social support conditions
"were not sufficiently in place for her
"to attend high school regularly.
"Because of this and her lack of friends, overall,
"as Kristen prepared to end her work with Lily
"she focused on connecting her
"with both peer and adult resources.
"One resource was the after school group
"that Kristen was co-facilitating called:
"Career Beginnings, and this was a group
"for college bound juniors and seniors
"to meet and learn about how to apply
"for financial aid and scholarships,
"writing the essays, et cetera.
"So Lily was able to come to one of those groups
"before Kristen left
"when Kristen was co-facilitating it,
"and Lily also agreed to continue to meet
"with Kristen's supervisor."
Kristen says: "We seemed to have created
"a bit of a holding environment
"for Lily at the school.
"I hope she will be able
"to use these supports after I leave."
So two final things before we wrap up.
Let's talk about where we are currently
about the research on change.
So we continue to see studies that provide support
for thinking about change as this complex,
dynamic interaction of multiple factors.
More specifically we're starting to have some
of the active ingredients,
and some specific treatments
being questioned through dismantling
our component analysis studies.
So, for example, in some CBT studies
they're finding that a focus on early attachment
or relationship dynamics
were also some of the key ingredients
that positively influenced change.
So while the current theories of change
such as CBT aren't wrong
we know that CBT theories
do focus more on cognition,
a little bit less on relationship,
a little bit less on emotion.
What we're finding is that the active ingredients
that we thought were active
in a particular theory
might not capture the full complexity
of what's going on.
So what this means then is that even though
specific techniques are being used
with a particular model,
other processes and activities are also happening,
and influencing the outcomes.
So there seems to be more going on
than what research has named for us.
This dovetails with the continued interest,
and research on common factors
that we're seeing across
various treatment modalities.
So in psycho-dynamic research, for example,
Peter Fonagy is beginning to talk
about mentalization as perhaps
functioning as a common factor
as a way of establishing trust,
and then openness to something new.
We see interesting common factors
in work with co-occurring disorders.
Within CBT there's been a study
that is looking at the commonalities across CBT's.
Within marriage and family therapy
we know there's a lot of work that has been done
on integrative work,
and also in the child therapies.
Chorpita, for example, has been working on
common elements that are the basis for
the majority of the child therapy
models and protocols.
So to conclude the Common Factors model
for me has been an organizing scaffold.
It's been a way for me to be able to use evidence
to draw on and to respond to some
of the contemporary challenges
that I outlined earlier,
so it helps understand how change place,
and it also helps guide thinking around
making decisions in the moment,
and overall with clients.
Thank you.
(applause)
So Dr. Drisko tells me that there's time
for some questions if anyone has anything.
- [Voiceover] I'd like to know where I can get more.
If I read your
published article where do you get
more of this in detail and depth?
- Yes, and the model itself
is the book that's published by Pearson,
so a lot of the slides about method,
and the factors and how to think about it.
So you let me just do a little PR on the book, huh?
Thank you Charlotte.
- [Voiceover] I'll get to follow up with your book.
- Okay, thank you.
Elizabeth.
- [Elizabeth] Yes, can you talk a little bit about
for new social work students
how you would see and review
clients for the first time
how you would begin to talk to them
about the Common Factor model.
They're struggling with "Oh my God,
"I'm seeing a plan for the first time."
and they're writing about these.
For them new models, new ideas,
new way of thinking,
so how do you begin to integrate?
You talked about your student E.
Maybe you could talk a little bit about
how did the two come together?
As a professor how do you help to bridge the two?
- I think, you know, just with many other
beginning practice it's engagement,
it's relationship, it's listening.
I think for me the other piece
that I emphasize a lot is really tuning in
to where the client is with energy and ability
to engage with the work
what we might call "motivation."
So there's often a lot of distress,
but sometimes they're distressed
because somebody else sent them there,
or there's distress, but maybe not the ability,
or the energy to do much about it right now,
and needing a lot of holding and support.
The facilitation method I say is:
"Talk to the hand," you know,
because it's five things, and so I really say:
"What did you just hear?"
And reflect on that, you know,
"What did you notice?"
And so you made that suggestion.
Did the person go do it?
And why do you think not?
So a lot of things that folks here in the room
who've been psycho-dynamically trained
would say: "Well, yeah, that's kind of what we do."
It's similar to, I think, what holds up
with Common Factors
because the relationship,
and the client and therapist factors are so key here
which really is the heart of psycho-dynamic work
as well so it's really not getting too far
ahead of where the client is of really listening.
- [Voiceover] What does the broad
case conceptualization look like?
How is it different from
the regular case conceptualization?
- In terms of conceptualizing a problem,
or a diagnosis it would not differ.
I think this is more additive.
So when I was saying that one wants to listen for
what's the capacity for change
that one writes up
what one notices about
the conditions that are sufficiently,
or insufficiently present,
and some of that could be some of what
we do in a psychosocial around
a client's social supports
would fall into some of that,
but I think there'd be more attention paid
onto where the client factors are, for example.
I'm not sure how much of
a broad conceptualization thinks about
distress and hope and active help seeking,
and whether a client thinks that therapy
is something that's credible or compatible
with one's belief system.
I think some of that is in addition to
a case conceptualization.
- [Voiceover] So if I hear you correctly
you're saying that client expectations
need to be addressed as well as the role
of Common Factor.
You also talked about motivation
as one of the key factors,
but is it according to the demoralization hypothesis
hope that's going to go around?
I mean you're making it one (mumbles)
Is that like a broad piece?
- Let me see if I'm following you right.
Motivation is kind of the big umbrella concept,
and distress and hope,
and beliefs and expectancy
are all like underneath that umbrella
like pieces of.
- [Voiceover] Many people kind of try
to make so many strands out of it,
and there's so many factors,
and you know that even Common Factors,
there are like now 35 Common Factors.
In terms of integrated theories
there are probably 100 integrated theories,
so where are we going ahead with this?
We started with 400 therapies,
and we said, you know what,
maybe there are Common Factors,
so where do you need the Common Factors?
Once we have the Common Factors
now we try to combine the Common Factors
in so many ways to have another theory.
So where are we going with this,
and why should social work embrace it?
- That's an excellent question.
So for me, again, it's not about the list.
Yeah-no, I mean when I was
at dinner with Dr. Drisko
I was just talking about the self-study we did
for re-accreditation and the 42 practice behaviors
that drove me crazy.
Yeah, so I get it.
So for me it's not about a laundry list
that I'm going down going
check, check, check, check, check,
but rather it's thinking about
from the client perspective
Lily was distressed,
but she really did not have hope
that things could be different,
so she would come in and just arrive, right, okay?
So one doesn't necessarily have to think about
each of these separately,
but what it does though is ...
For me anyway,
is thinking about not just
problem or diagnosis,
but for me it flips it to capacity for change.
It flips thinking into moving forward.
What do we have?
What is already there that I want to support,
and build on?
What might be missing that is such a barrier
that absolutely nothing's gonna happen
until we look at this.
So that's kind of how I deal with it.
- [Voiceover] So what I hear is, again,
we are kind of locating the problem in the client
saying there's no capacity for change,
or there's no hope,
but is this a bit of shift from looking at the problem
(mumbles) the client,
and then working on it.
Isn't that our role as social workers?
- It sure is, so I just zoomed into some
client factors right there,
but that's why there are therapists,
and social network factors.
My examples, the teachers
in the Child Development Center, right?
And the lack of collaboration
within the Elder Care Community,
and the countertransference reactions
within the therapists are all conditions
that needed to be identified with
the facilitation method, you know,
of noticing in the moment,
and needed a response so that the client
would not get blamed,
so that it's not a blame the victim kind of thing.
So for me it helps hold out
the full spectrum of conditions
that all influence the work
with the method kind of trying
to keep your attention roaming,
and noticing when something over here
is what really needs to be addressed
in the organization or within the community,
or a policy, for example.
Something that's oppressive,
an oppressive practice.
Because I think you're absolutely right,
that that's what I've been trying to work towards
in conceptualizing it this way.
Yeah, Brian.
- [Brian] I'm assuming that you teach this model
to both BSW and MSW students,
and when you do that I'm kind of curious
how you tease out kind of a scope of practice
with that for those different levels?
- Are you thinking about undergrad or grad more
just so I know where you're headed with this.
- [Brian] What I'm thinking was the problem
we have back home where hospital administrators
are saying: "L"et's just hire these BSW's
"because from my perspective
"they appear to be doing the same thing
"that MSW's are doing.
"I can't tell the difference."
Help me understand the difference.
That's what these non-social work administrators
who like to save dollars
are saying about the scope of practice.
So that's why I'm kind of curious.
How that gets teased out
when we have a model like this
that's this broad.
- Okay, well first of all in Connecticut, anyway,
we have the reverse problem
where most people don't want to hire BSW's.
They want the MSW's that can get licensed,
and do third party reimbursement,
but having said that let's stay with your question.
Well, I'm gonna toot my own horn here.
In the clinical Social Work Journal
the final article in the special issue is called:
"From Silos to Scaffolding."
In there Dr. Grady and I write about
how we envision Common Factors
as the scaffold to which you put
specified treatments,
so if you've got these processed strategies
you can think about how DBT, for example,
or EMDR, whatever,
are more specific versions
of interpersonal learning, right?
Or practice and reinforcement.
And so it's still keeping this idea
of capacity and how we're moving
forward with change,
and then it's inserting on top a particular treatment
that might be indicated or might be pretty useful
because it gives you some clearer guidance
for a particular diagnosis or a particular
psychosocial problem,
so that's kind of where I situate it,
so I view Common Factors as kind of
a solid foundation and in many ways it can work,
and I think it can work in the absence
of more specified things,
but then we certainly know
we've got perfectly good practice models identified
that I think could be wired in
with just some thinking about how
they're more specific examples.
- [Voiceover] I'm curious what are
the things that worry you about, like,
what keeps you up at night about these problems?
Like, where are the areas where you're thinking
oh I haven't quite know that downer.
It can't be how does scaffolding needs
adds to the house
because it's like the doghouse right now,
or does not play in there.
If you know what I mean?
- I do, there's not enough on social action.
We've got one lone advocacies process.
So it's not even close to the house.
That's a great question, yeah,
so for it truly to, I think,
represent social work in all its fullness,
yeah, it needs more of that.
I think what it's helped with is
organizational practice
thinking about the social workers policies,
procedures, funding sources.
It really identifies so much of what we find
challenging and problematic is
we practice in the field,
but it doesn't get to social change
in the way that I think that it needs to.
- [Voiceover] It's an annoying question,
so my apologies at the outset.
I was wondering how is it
that your conceptualizing change
within this model?
- I think, you know, it's kind of
all of Bronfenbrenner, it's ecological.
So that would be another area,
so for people who want to go do more research
who want to nail it down more,
and get more specific
I think that's where the work needs to be,
so it's general.
Conditions and processes they interact,
and they produce change.
Castonguay, for example,
has been highlighting for us.
Some of the surprises we're finding,
and there's a ton of research
that still needs to be done to say
well, if this, then this, and under this condition,
and then we get this, right?
Well, there's about five more decades
of research right there, right?
Do you want to do it?
- [Voiceover] I think some of these topics
have been really interesting
because they point to how complicated
change in human beings and systems are,
and a lot of what you're pointing out, I think,
is something that we've got to give
Ms. Keenan credit for and Mark Cameron.
These models were developed by psychologists,
and they really focused on process,
and therapist variables,
and they almost left the client down with it.
One of the things that's kind of obvious
when you bring a social work perspective
is that the client brings a lot too.
This process doesn't happen by itself, right?
And then you get into not only that,
but as you were saying
who supports the social worker doing the work,
and what kinds of thing happen
that are kind of in the dance?
Can the client get to the agency?
All the kind of stuff that we know,
and so forth, those matters,
and life functions, and policy and payment.
There's just so much out there
that how you put it together,
and how you think about it
is incredibly complicated,
and to make the model allow for more
variations is actually part of what we have to do
which in some ways makes the model
seem more difficult,
but it maybe gets a little closer to real life,
and I think that's what you and Dr. Cameron
have been trying to do.
- [Voiceover] Professor, I have a question for you.
If this model, like you say,
was developed by psychologists
and it focuses more on the therapist variables,
and the process variables
do you think it's a good model,
and it seems more-so just for
micro practice kind of a thing.
Do you think it's a good model
for social worker embrace and go ahead with?
I don't know.
- Well, just to clarify.
The research that identifies some of the factors
comes largely from psychologists,
and then what Dr. Drisko has added,
and in our own research
we have included social workers
who have done research
that focus in on some of these
social network factors,
that look at a little bit more about
material resources and the impact
of various social supports,
for example, on a family.
So putting that together
you're right that I think the model fits best
with direct practice,
so work with individuals, or families, or groups,
practice within communities, within organizations.
And as I was saying to this other woman
I would look and do look for other models
for social change.
I can use a lot of these ideas.
I can still look to see and listen for capacity.
I can look to see what conditions are missing,
and then I'm just taking categories,
and just shifting and applying.
And, you know, this may not play out.
It may not end up being useful,
and so we'll keep looking, right? Yeah.
- [Voiceover] I'm not sure if I fully
form this question,
but I'm gonna try it anyway
which is so a lot of this
is sort of a kind board
that warrants motivation and expectancy
and hope within the client.
I'm wondering whether you have any advice,
especially for new clinicians,
to figure out is there any information about ways
in which unintentionally the way
in which you assess hope within
the therapeutic communication
when you are actually impeding
the client's ability to fully
assess that within themselves
depending on if you have a checklist
when they come in, one to 10,
or the way you ask the question, or ...
- Well, you've got it.
You just gave yourself the response
I was gonna say is usually checklists,
and structured assessments
are not gonna be as useful.
More open-ended questions
asking about times in the past
when they've encountered a challenge,
and how did they respond, how did it happen?
Did it seem workable for them?
So hearing stories about previous experiences,
asking what they think
is gonna happen in the future.
And you're right, so it's more like engaging
in a conversation with them
about what troubles them,
what keeps them awake at night,
and do they think it can be different,
and what would it take?
Yeah, that's a great question.
Are we good?
All right, thanks so much everyone.
(applause)