WEBVTT

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- [Dr. Drisko] We are very
pleased this year to have

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Dr. Elizabeth King Keenan

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who is a professor at
Southern Connecticut State

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in New Haven, Connecticut.

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She holds an MSW degree

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from Loyola University of Chicago,

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and a Ph.D from

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the Smith College School for Social Work.

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Dr. Keenan has worked as a practitioner,

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and has also served as an adjunct

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faculty member here at Smith

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for the New York University
School of Social Work,

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and for Fairfield University.

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One of her innovations

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at Southern Connecticut

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has been to help develop approaches

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to support her faculty
with heavy teaching loads

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to also be productive scholars.

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She's been successful in this effort,

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and earned the gratitude
of her colleagues,

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and also the profession.

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She was a speaker two
years ago at the group

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for the Advancement of Doctoral Education

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speaking on just this topic.

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In her own scholarship Dr. Keenan

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has been recently the co-editor with

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Melissa Grady of a special issue

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of Clinical Social Work Journal entitled:

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"Beyond the Manual: Using Research

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"and Evidence in Clinical
Social Work Practice."

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This issue is now out electronically,

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and is due out quite soon in print.

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With her colleague Mark Cameron,

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Dr. Keenan is the author
of a book entitled:

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"The Common Factors Model

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"for Generalist Practice"

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just published by Pearson in 2012.

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She's the author of many journal articles,

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and notable in this area
is an article entitled:

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"The Common Factors Model:

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"Implications for
Trans-theoretical Clinical

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"Social Work Practice"

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which she authored with Dr. Cameron,

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and was published in social work.

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Also, another article that I like a lot,

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and I really like the title called:

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"From bumps in the road
to the edge of chaos:

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"The nature of change in adults."

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This was published in

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the International Social
Work Journal in 2001.

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We are very fortunate
tonight to have with us

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Dr. Keenan who is a talented clinician,

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educator, and scholar,

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and we're happy to have her with us

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as the Brown Foundation lecturer for 2014.

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Dr. Elizabeth Keenan.

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(applause)

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- Thank you Dr. Drisko, thanks everybody.

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Tonight I'm going to be using

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a few case examples from various students

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that I've been working
with and learning with,

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and I want to extend my gratitude to them

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as well as to all the
students and colleagues

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and supervisees who use various versions

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of this work while it was in process.

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So after working as a music director

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for several years, I decided to go back,

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and get my MSW in my late 20's.

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I wanted to get to know the stories behind

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the weddings, and the
baptisms, and the funerals,

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and the hundreds of couples and families

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that I had only briefly
met when I talked with them

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about what music they
wanted for these events.

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I wanted in depth conversations.

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I was hungry to hear the backstory.

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I wanted challenges, and I got it.

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At Loyola University of Chicago

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I learned about psychodynamic theory.

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At my internship I learned how to create

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therapeutic relationships,

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and track clinical process with adults,

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and in my other internship with children

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in a school setting

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I learned how to create
a holding environment

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in the only space available

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in the basement next to the heating pipes.

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Quite a challenge.

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But my practice experience
after graduation,

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however, left me feeling pretty perplexed.

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I faced quandaries,

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and so many moments of uncertainty.

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I was working with
families and individuals

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from preschool age to elders,

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and encountering what
felt like at least half

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of the diagnoses from the DSM,

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as well as a range of
trauma and grief reactions

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from family and community violence

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in neighborhoods while I worked

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at a Community Mental Health Center,

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a Family Service Agency,

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and a Town Counseling Center.

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So what could I use to guide my practice,

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and how could I possibly become proficient

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with all the practice models

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that were being created for

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a range of people I worked with.

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I went on a quest attending numerous

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continuing ed seminars,

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and reading just about anything

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I could get my hands on

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searching for ways to deal
with this uncertainty.

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This quest led me to the Ph.D

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program here at Smith.

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I started to find my footing again

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as I learned about decades of research

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that examined many of these same dilemmas

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as well as clinicians who were trying

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to craft innovative responses.

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So before we continue

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I invite you to take a moment,

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turn to someone next to you,

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and just share what is it

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that anchors your practice.

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What guides your thinking?

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So take a minute and talk
that out with someone.

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(chatter)

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Okay, can I invite you to come back

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to the larger room.

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It's great to hear your energy out there.

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Now I feel like we're all
ready to go, all right.

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So as we move on

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we start thinking about what is

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the story of us as social workers.

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We've talked about our dilemmas,

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what anchors us,

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and throughout the
history of our profession

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we have encountered these

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dilemmas and challenges.

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In the first several
decades of our history

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there were a few primary theories

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that were developed.

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Psycho-dynamic, behavioral, cognitive,

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functional, humanism,

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and then family and group models,

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and each new theory is a response to a gap

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that was not being met,

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or was perceived to be there

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from previous models.

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So then research on psychotherapy,

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and various models also
started to take place

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starting in the 20's.

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Research has looked at
these theoretical models

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in three different ways.

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So first of all overall
efficacy and effectiveness.

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So when we're looking at efficacy

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what we're thinking about
is internal validity.

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Does it work under certain conditions,

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and effectiveness, external validity.

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Can I use this model with
another group of people

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in a different setting,

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in a community setting, for example.

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So we have over 50 years of research

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with thousands of studies,

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and has generated evidence
that psychotherapy,

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yes, is helpful, and it does help

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clients make meaningful changes.

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Then we have comparative
effectiveness studies

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that look at different practice

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models with each other.

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Rosenzweig, in 1936 was the first to pause

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at the hypothesis that in general

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no one model really is superior to others,

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and he quoted the Dodo bird from

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"Alice in Wonderland" who said:

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"Everybody has won and
all must have prizes."

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Since that time research
still finds little,

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or no substantial difference
between therapies,

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and what we mean by this is:

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Similar numbers of clients do improve

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across different kinds of treatments.

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Then, finally, we have
process outcome research,

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and that seeks to identify and understand

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what are the factors
that influence change,

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how do they interact.

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We've been identifying several factors,

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and then calling them
into question ever since.

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So when learning about these

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different bodies of research

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I was excited to learn some of the things

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that I had paid attention
to like the relationship,

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the clinical process,

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were being examined in research.

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I was still troubled, though,

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because some of the
groups that I worked with

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remained underrepresented
in this research.

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That includes LBGT youth and adults,

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various racial and ethnic groups,

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and people who are experiencing

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multiple psychosocial problems.

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I was also troubled because many people

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still are not helped by psychotherapy.

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Some drop out prematurely,

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and some do not benefit,

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so clearly more work needs to be done.

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So since I finished my Ph.D in 2001

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more work has been done.

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People have been
generating numerous amounts

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of additional practice models

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for some of the populations

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that I mentioned that
were being marginalized,

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or not thought about,

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but also innovative different models.

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So from good therapy that had to work

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what you see here is
just the practice models

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beginning with the letter "I."

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There are hundreds of them, go look.

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In addition, those who pay for services

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are asking for increased
accountability by us.

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They're asking us to use models that work,

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and they're asking us to demonstrate

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that what we do is effective.

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So this push for accountability

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has led to more research
on what is being done,

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and there are several sites

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that publish some of the work,

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and three of them are here on the slide.

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For example, SAMHSA lists

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335 programs and practices

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in their national
registry of evidence-based

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programs and practices.

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Yet, despite all of these
new models and research

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we have choices, we have more challenges.

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I'll highlight four.

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How do clinicians in
organizations select from,

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for example, these 335
programs and practices

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especially in the face of budget cuts,

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and constraints for resources.

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So we know evidence-based practice, EBP,

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is a process that helps
guide the selection,

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and make these decisions,

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but the process itself requires skills,

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time, and resources that
are hard to come across

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at organizations that
address multiple kinds

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of psychosocial problems and disorders.

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Next, EBP says to make decisions using

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the integration of the
best research evidence

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with clinical expertise and client values.

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So if a client's beliefs
are not consistent

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with a practice model
that has strong evidence

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what do you do?

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How do you use your expertise in ways

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that respond to the clients

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preferred ways of working?

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Or three, what do you when specific

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client attributes, or
combinations of problems

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don't fit a model that
has empirical support.

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Do you adapt the model?

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We have implementation science

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that's beginning to do that,

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but how do we know if we're adapting it,

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and then leaving out an ingredient that is

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a key ingredient that affects change.

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And, finally, we still
have some competing,

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and conflicting research evidence,

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and an example of that is, again,

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from the SAMHSA website.

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It says: "Decades of
careful scientific research

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"indicates that psychotherapy success

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"is influenced by ... "

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Well, you can see it,

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just about everything, right?

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However, the therapy relationship

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accounts for why clients improve,

274
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or fail to improve as much as

275
00:14:15.210 --> 00:14:17.750
the particular treatment method.

276
00:14:17.750 --> 00:14:19.610
SAMHSA believes these research findings

277
00:14:19.610 --> 00:14:22.980
may compliment and/or
augment the information

278
00:14:22.980 --> 00:14:26.400
contained in those 335
intervention summaries.

279
00:14:27.560 --> 00:14:30.120
Okay, but what does compliment,

280
00:14:30.120 --> 00:14:32.730
or augment mean in practice?

281
00:14:32.730 --> 00:14:34.860
How does one do that?

282
00:14:34.860 --> 00:14:37.210
How do you put that together?

283
00:14:38.230 --> 00:14:40.180
So, more confusion.

284
00:14:40.700 --> 00:14:43.120
More information, more confusion.

285
00:14:43.740 --> 00:14:45.330
I was still a little stuck trying to

286
00:14:45.330 --> 00:14:46.340
figure out what to do

287
00:14:46.340 --> 00:14:48.180
so I started having conversations

288
00:14:48.180 --> 00:14:50.980
with my colleague Mark Cameron.

289
00:14:50.980 --> 00:14:53.630
He and I decided it was
time to find a third way.

290
00:14:55.523 --> 00:14:58.290
A model of change that
looked at relationship,

291
00:14:58.290 --> 00:15:00.030
and method together,

292
00:15:00.030 --> 00:15:01.590
not in complimentary ways,

293
00:15:01.590 --> 00:15:04.890
but in an effective,
workable practice framework.

294
00:15:04.890 --> 00:15:06.660
Our thinking was to create a model

295
00:15:06.660 --> 00:15:09.460
that could be used as the default mode.

296
00:15:09.460 --> 00:15:12.000
The what we always do mode

297
00:15:12.000 --> 00:15:13.600
that could serve as a scaffolding

298
00:15:13.600 --> 00:15:15.900
for specific treatments.

299
00:15:15.900 --> 00:15:18.410
So we started putting together this model

300
00:15:18.410 --> 00:15:20.270
by looking at the empirical evidence

301
00:15:20.270 --> 00:15:23.472
for what's in common across models.

302
00:15:25.380 --> 00:15:28.380
Michael Lambert is someone who has helped

303
00:15:28.380 --> 00:15:30.350
provide various categories

304
00:15:30.350 --> 00:15:32.620
identifying what might be in common,

305
00:15:32.620 --> 00:15:35.570
and he came up with four categories.

306
00:15:36.920 --> 00:15:39.630
The therapist techniques, expectancy,

307
00:15:39.630 --> 00:15:43.230
the belief or hope that change can happen,

308
00:15:43.230 --> 00:15:45.300
relationship factors,

309
00:15:45.300 --> 00:15:47.300
and then client and environment factors,

310
00:15:47.300 --> 00:15:50.500
or what he called "extra therapeutic."

311
00:15:50.500 --> 00:15:52.470
So let's stop for a minute.

312
00:15:52.470 --> 00:15:55.510
If we think about the influence

313
00:15:55.510 --> 00:15:58.780
of all four of these factors

314
00:15:58.780 --> 00:16:01.550
totaling up to 100%

315
00:16:01.550 --> 00:16:03.280
which one of these do you think

316
00:16:03.280 --> 00:16:06.190
has the greatest amount of influence

317
00:16:06.190 --> 00:16:08.020
on outcome variance?

318
00:16:08.020 --> 00:16:10.170
Which one would have
the greatest influence?

319
00:16:10.170 --> 00:16:13.990
What percentage would you put to it?

320
00:16:13.990 --> 00:16:16.100
So take a minute and think about that,

321
00:16:16.100 --> 00:16:18.150
and then I'll show you what Lambert said.

322
00:16:27.040 --> 00:16:29.390
Ready? Okay, here we go.

323
00:16:31.010 --> 00:16:33.710
So the client factors

324
00:16:33.710 --> 00:16:36.620
have the largest influence score

325
00:16:36.620 --> 00:16:39.370
in the back there, excellent.

326
00:16:41.066 --> 00:16:43.730
Followed by common factors,

327
00:16:43.730 --> 00:16:46.790
and the key thing that we learn is that

328
00:16:46.790 --> 00:16:49.130
therapist techniques have only

329
00:16:49.130 --> 00:16:52.330
a small influence on outcomes.

330
00:16:52.330 --> 00:16:54.670
So in looking at this literature we knew

331
00:16:54.670 --> 00:16:57.240
that we needed to include
not just techniques,

332
00:16:57.240 --> 00:16:58.470
and relationship factors,

333
00:16:58.470 --> 00:17:00.940
but we had to look at
other factors as well.

334
00:17:00.940 --> 00:17:04.210
So we kept exploring, and next we turn to

335
00:17:04.210 --> 00:17:06.810
Grinkevich and Norcross,

336
00:17:06.810 --> 00:17:09.390
and they reviewed 50
publications to identify

337
00:17:09.390 --> 00:17:12.950
commonalities across
therapeutic common factors.

338
00:17:12.950 --> 00:17:16.120
Client therapist and relationship factors,

339
00:17:16.120 --> 00:17:18.690
and here's something interesting

340
00:17:18.690 --> 00:17:21.400
where they start to diverge from Lambert.

341
00:17:21.400 --> 00:17:24.900
They came up with a
category called "processes"

342
00:17:24.900 --> 00:17:27.070
that produced positive outcomes.

343
00:17:27.070 --> 00:17:30.140
So this is not techniques, but processes,

344
00:17:30.140 --> 00:17:32.410
transtheoretical means,

345
00:17:32.410 --> 00:17:34.580
and we'll get into what that
means a little bit later,

346
00:17:34.580 --> 00:17:36.880
but I just want to draw
your attention to that.

347
00:17:36.880 --> 00:17:38.550
So we had the beginnings

348
00:17:38.550 --> 00:17:41.480
of some ideas for a model.

349
00:17:41.480 --> 00:17:44.750
Client processes, therapists,

350
00:17:44.750 --> 00:17:47.710
but we still hadn't figured out what to do

351
00:17:47.710 --> 00:17:50.760
with those areas in red.

352
00:17:50.760 --> 00:17:52.430
Social and material supports,

353
00:17:52.430 --> 00:17:55.560
organization and
professional helping system.

354
00:17:55.560 --> 00:17:58.130
We wanted and knew we needed to include

355
00:17:58.130 --> 00:18:00.730
something about these
extra therapeutic factors

356
00:18:00.730 --> 00:18:02.500
because we are social workers,

357
00:18:02.500 --> 00:18:05.210
and we know how much the environment,

358
00:18:05.210 --> 00:18:08.180
and the interaction between key people

359
00:18:08.180 --> 00:18:11.410
in client's lives affects what happens

360
00:18:11.410 --> 00:18:13.710
to a person's well being,

361
00:18:13.710 --> 00:18:15.320
and it also felt important because

362
00:18:15.320 --> 00:18:16.820
we knew we needed to take a look

363
00:18:16.820 --> 00:18:18.620
at the issue of power.

364
00:18:18.620 --> 00:18:21.560
Not just relational power as a healing,

365
00:18:21.560 --> 00:18:22.860
or curative factor,

366
00:18:22.860 --> 00:18:26.130
but also power as its exercised

367
00:18:26.130 --> 00:18:28.500
within, and between groups of people,

368
00:18:28.500 --> 00:18:32.300
within organizations, within communities.

369
00:18:32.300 --> 00:18:36.390
So, thankfully, we have Dr. Drisko

370
00:18:37.200 --> 00:18:40.010
who provided us some language

371
00:18:40.010 --> 00:18:42.110
to flush out these extra

372
00:18:42.110 --> 00:18:44.760
therapeutic factors of Lambert.

373
00:18:45.750 --> 00:18:47.250
So Dr. Drisko brought

374
00:18:47.250 --> 00:18:49.720
the person in environment perspective,

375
00:18:49.720 --> 00:18:52.250
the lens to Lambert's conceptualization,

376
00:18:52.250 --> 00:18:56.550
and he helped identify
policy and agency context

377
00:18:56.550 --> 00:18:59.890
of the therapist as well as

378
00:18:59.890 --> 00:19:03.610
aspects of the client context
and client attributes.

379
00:19:04.400 --> 00:19:07.990
So we were ready now
to construct our list.

380
00:19:09.640 --> 00:19:11.140
So Dr. Cameron and I renamed

381
00:19:11.140 --> 00:19:12.470
a couple of the categories.

382
00:19:12.470 --> 00:19:14.490
We put our list together.

383
00:19:17.040 --> 00:19:19.355
And we then began to conceptualize things

384
00:19:19.355 --> 00:19:23.300
as an ecology of conditions and processes.

385
00:19:25.290 --> 00:19:28.767
So as we switch here

386
00:19:28.767 --> 00:19:32.160
I just want to emphasize this one piece.

387
00:19:32.160 --> 00:19:35.630
A list is fine, but a list
doesn't guide practice.

388
00:19:35.630 --> 00:19:36.900
A list doesn't help us know

389
00:19:36.900 --> 00:19:38.200
what to do in the moment,

390
00:19:38.200 --> 00:19:41.040
so we had to back up once again and say:

391
00:19:41.040 --> 00:19:43.300
"What is our understanding

392
00:19:43.300 --> 00:19:45.840
"of how change occurs in therapy,

393
00:19:45.840 --> 00:19:48.150
"how change occurs in
social work practice."

394
00:19:49.710 --> 00:19:51.580
So more and more evidence suggests

395
00:19:51.580 --> 00:19:53.810
that it is not a linear way,

396
00:19:53.810 --> 00:19:56.430
it's not a linear path
of the medical model,

397
00:19:57.320 --> 00:19:59.890
but rather research suggests,

398
00:19:59.890 --> 00:20:02.490
and we know from our clinical experience

399
00:20:02.490 --> 00:20:05.250
that change in psychosocial functioning

400
00:20:05.250 --> 00:20:08.430
occurs through dynamic interactions

401
00:20:08.430 --> 00:20:11.610
of multiple contributing factors.

402
00:20:13.830 --> 00:20:16.970
So none of these factors operate alone,

403
00:20:16.970 --> 00:20:19.600
and no one factor

404
00:20:19.600 --> 00:20:23.340
is the one factor that causes change.

405
00:20:23.340 --> 00:20:26.310
Rather, they are in a constant flux

406
00:20:26.310 --> 00:20:29.720
of interaction and interdependence.

407
00:20:29.720 --> 00:20:31.450
Now we're getting a little abstract here

408
00:20:31.450 --> 00:20:33.990
so we need to switch
things up a little bit,

409
00:20:33.990 --> 00:20:35.360
and try and see if we can't get

410
00:20:35.360 --> 00:20:37.260
a feel for what's going on here.

411
00:20:37.260 --> 00:20:40.480
So let's switch into a
gardening kind of mode.

412
00:20:43.400 --> 00:20:44.830
How many are gardeners?

413
00:20:44.830 --> 00:20:47.100
Flowers, vegetables, fruit?

414
00:20:47.100 --> 00:20:49.370
Excellent, okay.

415
00:20:49.370 --> 00:20:50.440
Me, not so much.

416
00:20:50.440 --> 00:20:51.510
I like the indoor plants

417
00:20:51.510 --> 00:20:52.670
I can water once a week,

418
00:20:52.670 --> 00:20:55.480
and they kind of survive, you know,

419
00:20:55.480 --> 00:20:57.510
they like a little light and we're good.

420
00:20:57.510 --> 00:20:59.810
Nonetheless, I've watched
a lot of people garden,

421
00:20:59.810 --> 00:21:02.180
and here's what I've noticed.

422
00:21:02.180 --> 00:21:03.720
So you get your seeds,

423
00:21:03.720 --> 00:21:05.860
and you got to pick the soil,

424
00:21:05.860 --> 00:21:09.490
and you need to find
the right kind of light,

425
00:21:09.490 --> 00:21:11.330
and the right climate.

426
00:21:11.330 --> 00:21:14.430
If you're outdoors, not
too hot, not too cold,

427
00:21:14.430 --> 00:21:15.500
and you plant things,

428
00:21:15.500 --> 00:21:17.275
and you hope that you don't have a freeze

429
00:21:17.275 --> 00:21:19.670
like we did when we
planted sunflower seeds,

430
00:21:19.670 --> 00:21:22.670
and nothing came up,

431
00:21:22.670 --> 00:21:24.170
but you also have to be paying

432
00:21:24.170 --> 00:21:26.574
attention to the pacing.

433
00:21:26.574 --> 00:21:29.310
So if all of a sudden
it's 80 degrees in June,

434
00:21:29.310 --> 00:21:31.850
and that's not working for your plants,

435
00:21:31.850 --> 00:21:35.280
then they're gonna get a little burnt,

436
00:21:35.280 --> 00:21:37.250
maybe a little droopy.

437
00:21:37.250 --> 00:21:39.420
So the key thing here is that

438
00:21:39.420 --> 00:21:42.260
you've got conditions of soil,

439
00:21:42.260 --> 00:21:43.920
and temperature,

440
00:21:43.920 --> 00:21:47.430
and rain, and light,

441
00:21:47.430 --> 00:21:51.200
but they need to interact
with the seed itself

442
00:21:51.200 --> 00:21:53.830
in particular kinds of ways,

443
00:21:53.830 --> 00:21:56.320
and at the right timing and pacing.

444
00:21:57.170 --> 00:21:59.570
So let's switch now to Winnicott,

445
00:21:59.570 --> 00:22:02.240
and a holding environment, right?

446
00:22:02.240 --> 00:22:05.330
So if the seeds are the
metaphors for clients,

447
00:22:06.780 --> 00:22:09.520
the soil and the terrain is some of what

448
00:22:09.520 --> 00:22:12.290
the therapist uses as
a holding environment.

449
00:22:12.290 --> 00:22:14.460
It's the therapists social network.

450
00:22:14.460 --> 00:22:16.120
Where are you meeting?

451
00:22:16.120 --> 00:22:18.230
How supportive is it?

452
00:22:18.230 --> 00:22:19.430
What are all the procedures,

453
00:22:19.430 --> 00:22:21.500
and the paperwork, and the documentation,

454
00:22:21.500 --> 00:22:22.700
and the reimbursement,

455
00:22:22.700 --> 00:22:24.620
and are you feeling welcomed.

456
00:22:25.570 --> 00:22:27.800
Then the rain and the sun and the shade

457
00:22:27.800 --> 00:22:29.300
are the other aspects,

458
00:22:29.300 --> 00:22:32.040
the activities that we provide,

459
00:22:32.040 --> 00:22:35.240
efforts to listen, acceptance, empathy,

460
00:22:35.240 --> 00:22:36.953
and then we pay attention to

461
00:22:36.953 --> 00:22:38.710
how well can the seed,

462
00:22:38.710 --> 00:22:40.570
how well can the client take it in.

463
00:22:41.820 --> 00:22:43.280
Can the person experience it?

464
00:22:43.280 --> 00:22:45.450
Are they ready, are they at a point

465
00:22:45.450 --> 00:22:47.890
that the client is able to engage with it.

466
00:22:47.890 --> 00:22:50.170
So when Dr. Cameron and I conceptualized

467
00:22:50.170 --> 00:22:52.890
how these factors produce change

468
00:22:52.890 --> 00:22:56.530
we noticed that these factors
functioned differently.

469
00:22:56.530 --> 00:22:58.790
Some were conditions,

470
00:22:58.790 --> 00:23:01.600
others are processes.

471
00:23:01.600 --> 00:23:04.170
And that we knew that an ecological model

472
00:23:04.170 --> 00:23:06.870
of them interdependently interacting

473
00:23:06.870 --> 00:23:09.160
is where we wanted to go.

474
00:23:09.900 --> 00:23:11.310
So I'm gonna move through a couple

475
00:23:11.310 --> 00:23:13.080
of these things pretty quickly here.

476
00:23:13.080 --> 00:23:16.450
Conditions are essential
qualities or attributes

477
00:23:16.450 --> 00:23:19.300
necessary for change and here's a list:

478
00:23:20.890 --> 00:23:23.510
We have individual and family conditions.

479
00:23:25.330 --> 00:23:28.560
There's you see, the
expectation, the hope.

480
00:23:28.560 --> 00:23:30.810
Social worker conditions.

481
00:23:32.130 --> 00:23:33.870
Our empathy, our acceptance.

482
00:23:33.870 --> 00:23:36.370
Social network conditions,

483
00:23:36.370 --> 00:23:39.210
those policies and funding procedures.

484
00:23:39.210 --> 00:23:41.340
We have processes that are activities

485
00:23:41.340 --> 00:23:44.680
carried out by one or more participants.

486
00:23:44.680 --> 00:23:46.610
We have relationship processes,

487
00:23:46.610 --> 00:23:49.420
engagement, collaboration,

488
00:23:49.420 --> 00:23:50.950
productive communication,

489
00:23:50.950 --> 00:23:53.690
mutual agreement on what we're about

490
00:23:53.690 --> 00:23:56.070
as well as change strategies.

491
00:23:58.390 --> 00:24:00.896
And here's the interaction.

492
00:24:00.896 --> 00:24:02.100
So the change strategies,

493
00:24:02.100 --> 00:24:04.430
and relationship processes

494
00:24:04.430 --> 00:24:07.450
help to enhance or establish conditions,

495
00:24:08.760 --> 00:24:11.340
interact with them and produce

496
00:24:11.340 --> 00:24:13.940
successful outcomes.

497
00:24:13.940 --> 00:24:15.826
So now let's bring it to the ground,

498
00:24:15.826 --> 00:24:18.430
and start talking about a case example.

499
00:24:19.350 --> 00:24:21.480
So Kristen is a white female intern

500
00:24:21.480 --> 00:24:23.550
of mixed northern European descent

501
00:24:23.550 --> 00:24:25.380
in her mid 20's.

502
00:24:25.380 --> 00:24:29.420
Her client Lily is a
17-year-old bi-racial female,

503
00:24:29.420 --> 00:24:31.630
Japanese and Caucasian

504
00:24:31.630 --> 00:24:33.190
currently living with her father

505
00:24:33.190 --> 00:24:35.220
in an urban area in Connecticut.

506
00:24:35.220 --> 00:24:38.470
Early childhood
information is a big vague,

507
00:24:38.470 --> 00:24:40.070
but Kristen knows that Lily's mother

508
00:24:40.070 --> 00:24:42.770
abandoned her at a young age.

509
00:24:42.770 --> 00:24:45.240
Lily lived for a few years with her dad,

510
00:24:45.240 --> 00:24:46.910
but he became either unwilling,

511
00:24:46.910 --> 00:24:48.670
or unable to care for her

512
00:24:48.670 --> 00:24:49.910
at which point she went to live

513
00:24:49.910 --> 00:24:52.680
with her father's sister, her aunt,

514
00:24:52.680 --> 00:24:55.939
until her aunt's friend
raped her one year ago

515
00:24:55.939 --> 00:24:59.350
resulting in child protective
service involvement.

516
00:24:59.350 --> 00:25:02.860
The father asked that
Lily be reunited with him,

517
00:25:02.860 --> 00:25:06.090
and after a home study
full custody was awarded,

518
00:25:06.090 --> 00:25:08.660
but the father still
remains largely unavailable

519
00:25:08.660 --> 00:25:12.316
working 12 to 16 hour shifts at a factory.

520
00:25:12.316 --> 00:25:14.180
Lily works at a restaurant in addition

521
00:25:14.180 --> 00:25:16.270
to attending school.

522
00:25:16.270 --> 00:25:18.710
She's tested at the above average level,

523
00:25:18.710 --> 00:25:21.340
and is placed in AP courses.

524
00:25:21.340 --> 00:25:23.330
She does not put forth much effort though,

525
00:25:23.330 --> 00:25:25.750
and has pretty poor attendance.

526
00:25:25.750 --> 00:25:27.280
From what Kristen could gather

527
00:25:27.280 --> 00:25:28.880
Lily's aunt tried to play the role

528
00:25:28.880 --> 00:25:30.820
of a nurturing parent,

529
00:25:30.820 --> 00:25:32.720
but also verbally abused her,

530
00:25:32.720 --> 00:25:34.760
and did not protect Lily

531
00:25:34.760 --> 00:25:37.760
from being raped by the aunt's friend.

532
00:25:37.760 --> 00:25:39.930
Kristen began to surmise that

533
00:25:39.930 --> 00:25:42.430
this love/hurt combination

534
00:25:42.430 --> 00:25:45.000
might feel normal to Lily,

535
00:25:45.000 --> 00:25:46.130
and might be expected

536
00:25:46.130 --> 00:25:48.040
giver her history of abuse,

537
00:25:48.040 --> 00:25:51.000
and neglect, and instability.

538
00:25:51.000 --> 00:25:53.070
In addition, Lily seems to be replicating

539
00:25:53.070 --> 00:25:55.410
these dynamics with recent boyfriends.

540
00:25:55.410 --> 00:25:57.440
She says she's attracted to drama

541
00:25:57.440 --> 00:25:59.950
seeking men who are a bit older than her

542
00:25:59.950 --> 00:26:01.820
who are verbally abusive towards her,

543
00:26:01.820 --> 00:26:04.080
and cheat on her.

544
00:26:04.080 --> 00:26:06.020
So using a common factors model

545
00:26:06.020 --> 00:26:08.560
we're assessing not just
the presenting problems,

546
00:26:08.560 --> 00:26:10.060
and the psychosocial history,

547
00:26:10.060 --> 00:26:13.230
but we're also listening for capacity.

548
00:26:13.230 --> 00:26:15.100
We look for the degree to which we have

549
00:26:15.100 --> 00:26:18.670
what it takes for something new to happen.

550
00:26:18.670 --> 00:26:21.970
What conditions are
available to work with.

551
00:26:21.970 --> 00:26:24.240
What's missing or insufficiently present

552
00:26:24.240 --> 00:26:27.510
that needs to be cultivated
for change to occur.

553
00:26:27.510 --> 00:26:30.440
Because if change happens with complex

554
00:26:30.440 --> 00:26:32.410
interdependent interactions

555
00:26:32.410 --> 00:26:34.280
we need to make sure that those factors

556
00:26:34.280 --> 00:26:37.170
are there for it to take place.

557
00:26:38.820 --> 00:26:40.690
So do we have what it takes?

558
00:26:40.690 --> 00:26:43.290
If a condition is insufficiently present

559
00:26:43.290 --> 00:26:45.830
we then think about is
it going to interfere

560
00:26:45.830 --> 00:26:48.240
with us taking a step forward?

561
00:26:49.630 --> 00:26:51.720
Do we need to focus on
maybe not the beginning,

562
00:26:51.720 --> 00:26:54.000
but as the work continues,

563
00:26:54.000 --> 00:26:57.670
and here's those
conditions to assess again.

564
00:26:57.670 --> 00:27:00.670
So openness of the therapist.

565
00:27:00.670 --> 00:27:03.210
Kristen initially felt acceptance,

566
00:27:03.210 --> 00:27:05.730
genuineness, and empathy.

567
00:27:06.440 --> 00:27:08.350
Looking at the client factors,

568
00:27:08.350 --> 00:27:10.220
Lily was experiencing a great deal

569
00:27:10.220 --> 00:27:12.120
of emotional distress.

570
00:27:12.120 --> 00:27:13.820
She was willing to meet,

571
00:27:13.820 --> 00:27:16.160
and actively participating with Kristen,

572
00:27:16.160 --> 00:27:18.250
but she lacked hope and really had

573
00:27:18.250 --> 00:27:20.990
little expectation that
change could happen

574
00:27:20.990 --> 00:27:22.500
that would be any different

575
00:27:22.500 --> 00:27:24.530
from the unpredictable change

576
00:27:24.530 --> 00:27:27.270
that was out of her control.

577
00:27:27.270 --> 00:27:30.200
When we look at the
client's social network

578
00:27:30.200 --> 00:27:32.040
no one seemed to be interfering

579
00:27:32.040 --> 00:27:34.240
with Lily's participation and counseling,

580
00:27:34.240 --> 00:27:36.949
but Lily did not appear
to have any significant

581
00:27:36.949 --> 00:27:39.740
relationship that was consistently caring,

582
00:27:39.740 --> 00:27:42.720
nor any close friends at the school.

583
00:27:42.720 --> 00:27:46.720
From the intern, the
social worker perspective,

584
00:27:46.720 --> 00:27:48.760
Kristen was providing these services

585
00:27:48.760 --> 00:27:50.360
at the Student Assistance Center

586
00:27:50.360 --> 00:27:51.930
in the high school,

587
00:27:51.930 --> 00:27:53.430
and they also had other services

588
00:27:53.430 --> 00:27:55.360
such as peer mediation,

589
00:27:55.360 --> 00:27:58.100
and groups on various issues,

590
00:27:58.100 --> 00:28:00.330
and the supervisor provided supervision

591
00:28:00.330 --> 00:28:02.317
for all of the interns.

592
00:28:02.317 --> 00:28:05.470
There was no worry about external funding,

593
00:28:05.470 --> 00:28:07.240
and you get to see the student

594
00:28:07.240 --> 00:28:09.210
in the educational environment.

595
00:28:09.210 --> 00:28:11.080
So to summarize the conditions,

596
00:28:11.080 --> 00:28:13.450
Lily was willing to meet with Kristen.

597
00:28:13.450 --> 00:28:15.280
She was distressed,

598
00:28:15.280 --> 00:28:16.692
but wasn't expecting

599
00:28:16.692 --> 00:28:18.250
that anything could be different.

600
00:28:18.250 --> 00:28:20.420
She lacked hope.

601
00:28:20.420 --> 00:28:23.370
She also lacked social supports.

602
00:28:24.390 --> 00:28:26.530
So Kristen noted that she wanted

603
00:28:26.530 --> 00:28:29.200
to pay attention and
monitor these conditions.

604
00:28:29.200 --> 00:28:30.520
She wanted to see whether Lily

605
00:28:30.520 --> 00:28:32.900
would really continue
to come to meet with her

606
00:28:32.900 --> 00:28:34.630
despite her lack of hope,

607
00:28:34.630 --> 00:28:38.010
how much of that would
affect her participation.

608
00:28:38.010 --> 00:28:41.140
And she also wanted to listen for

609
00:28:41.140 --> 00:28:43.510
how Lily would view Kristen

610
00:28:43.510 --> 00:28:45.150
given her history of abandonment,

611
00:28:45.150 --> 00:28:47.550
and recent trauma by caregivers.

612
00:28:47.550 --> 00:28:48.950
How might transference themes

613
00:28:48.950 --> 00:28:50.590
enter into the work.

614
00:28:50.590 --> 00:28:53.550
So that takes us now to
relationship processes,

615
00:28:53.550 --> 00:28:56.070
or are we working well together?

616
00:28:57.820 --> 00:29:00.260
So with the relationship processes

617
00:29:00.260 --> 00:29:01.800
not just engagement,

618
00:29:01.800 --> 00:29:03.600
but monitoring the communication

619
00:29:03.600 --> 00:29:05.170
throughout the work,

620
00:29:05.170 --> 00:29:08.970
having a mutual agreement,
and collaboration.

621
00:29:08.970 --> 00:29:11.340
So Lily was engaging with Kristen.

622
00:29:11.340 --> 00:29:14.010
She was sharing lots of details

623
00:29:14.010 --> 00:29:16.810
about past abandonments and abuse,

624
00:29:16.810 --> 00:29:19.880
and recent verbal abuse by a boyfriend,

625
00:29:19.880 --> 00:29:20.880
and she was doing it with

626
00:29:20.880 --> 00:29:23.620
a great deal of emotional intensity,

627
00:29:23.620 --> 00:29:26.990
but also a sense of this
is just the way it is.

628
00:29:26.990 --> 00:29:29.770
I'm upset about it and this is my life.

629
00:29:30.390 --> 00:29:33.360
So given Lily's history of
a lack of responsiveness.

630
00:29:33.360 --> 00:29:35.860
and attunement by her caregivers

631
00:29:35.860 --> 00:29:39.390
Kristen took Lily's lead
for the initial agreement.

632
00:29:39.390 --> 00:29:41.840
Lily said what she really wanted to do was

633
00:29:41.840 --> 00:29:44.240
make sure that she
graduated from high school.

634
00:29:44.240 --> 00:29:45.910
That was her priority,

635
00:29:45.910 --> 00:29:48.010
so Kristen went along with that,

636
00:29:48.010 --> 00:29:50.340
and hoped that focusing on the goal

637
00:29:50.340 --> 00:29:53.310
might help her to attend
school more regularly,

638
00:29:53.310 --> 00:29:56.590
and also support the
intellectual capacity she had.

639
00:29:57.250 --> 00:29:59.800
So what's the therapists role in all this?

640
00:30:01.790 --> 00:30:04.990
A clinician's role is to
facilitate this complex

641
00:30:04.990 --> 00:30:07.330
interaction of conditions and processes

642
00:30:07.330 --> 00:30:09.830
in the four ways that
are up on the screen.

643
00:30:09.830 --> 00:30:12.470
Having this initial
and ongoing assessment,

644
00:30:12.470 --> 00:30:15.470
making strategic judgments,

645
00:30:15.470 --> 00:30:17.270
facilitating collaborative agreements,

646
00:30:17.270 --> 00:30:19.585
and routinely monitoring and evaluating

647
00:30:19.585 --> 00:30:21.900
the process and the outcome,

648
00:30:21.900 --> 00:30:25.650
and you do it with the
facilitation method,

649
00:30:25.650 --> 00:30:27.910
a very simple thing of listening

650
00:30:27.910 --> 00:30:30.150
reflecting on what you've heard,

651
00:30:30.150 --> 00:30:32.590
strategizing, responding,

652
00:30:32.590 --> 00:30:34.930
and evaluating how it goes.

653
00:30:34.930 --> 00:30:37.290
So when things are going well

654
00:30:37.290 --> 00:30:40.130
this facilitation method happens

655
00:30:40.130 --> 00:30:42.700
largely out of our awareness.

656
00:30:42.700 --> 00:30:45.400
When we really want to use it

657
00:30:45.400 --> 00:30:47.900
is when we are getting stuck,

658
00:30:47.900 --> 00:30:49.440
or not sure of what to say,

659
00:30:49.440 --> 00:30:51.970
or we're caught off guard.

660
00:30:51.970 --> 00:30:53.810
We listen for and we evaluate

661
00:30:53.810 --> 00:30:56.010
how well things are interacting,

662
00:30:56.010 --> 00:30:58.950
but it's not what do I say,

663
00:30:58.950 --> 00:31:01.380
or what's the perfect response,

664
00:31:01.380 --> 00:31:03.810
it's more what am I thinking

665
00:31:03.810 --> 00:31:06.495
about how these factors are interacting,

666
00:31:06.495 --> 00:31:08.690
and what am I thinking would be key

667
00:31:08.690 --> 00:31:11.890
to help encourage as a next step.

668
00:31:11.890 --> 00:31:14.030
So we do this moment-by-moment,

669
00:31:14.030 --> 00:31:17.240
as well as with broad
case conceptualization.

670
00:31:19.700 --> 00:31:21.030
So back to Kristen.

671
00:31:21.030 --> 00:31:22.770
Kristen's initial thinking was to focus

672
00:31:22.770 --> 00:31:25.570
on a client condition.

673
00:31:25.570 --> 00:31:27.770
Lily's lack of belief and hope

674
00:31:27.770 --> 00:31:29.940
that things could be
different in her life.

675
00:31:29.940 --> 00:31:32.000
Kristen began to realize that not only

676
00:31:32.000 --> 00:31:35.520
did Lily have a belief
that change could happen

677
00:31:35.520 --> 00:31:37.380
she seemed drawn to keep things

678
00:31:37.380 --> 00:31:39.820
as familiar as possible.

679
00:31:39.820 --> 00:31:42.160
With this in mind Kristen says:

680
00:31:42.160 --> 00:31:44.090
"I started to explore to see if Lily

681
00:31:44.090 --> 00:31:46.130
"could identify something she might want

682
00:31:46.130 --> 00:31:48.090
"to reach for or work towards.

683
00:31:48.090 --> 00:31:50.260
"She started to talk about going to Yale

684
00:31:50.260 --> 00:31:51.830
"to be a pediatrician.

685
00:31:51.830 --> 00:31:53.750
"I thought I could use
this as an incentive,

686
00:31:53.750 --> 00:31:55.530
"a kind of carrot.

687
00:31:55.530 --> 00:31:56.840
"I was calling over to Yale,

688
00:31:56.840 --> 00:31:58.340
"and working with my supervisor

689
00:31:58.340 --> 00:32:01.110
"to try and organize a field trip.

690
00:32:01.110 --> 00:32:02.640
"As the weeks went on, though,

691
00:32:02.640 --> 00:32:04.810
"Kristen started to feel
an internal pressure

692
00:32:04.810 --> 00:32:07.410
"to help Lily achieve to be the adult

693
00:32:07.410 --> 00:32:10.080
"who wouldn't be like the other adults.

694
00:32:10.080 --> 00:32:11.280
"Kristen reflected on what

695
00:32:11.280 --> 00:32:13.020
"she was sensing internally,

696
00:32:13.020 --> 00:32:13.950
"and what she noticed

697
00:32:13.950 --> 00:32:16.220
"in Lily's communication with her.

698
00:32:16.220 --> 00:32:19.080
"I saw that my efforts
really weren't effective.

699
00:32:19.080 --> 00:32:21.360
"Seeing Lily's reactions I began to think

700
00:32:21.360 --> 00:32:24.830
"that just like a nurturing
relationship is frightful,

701
00:32:24.830 --> 00:32:28.470
"so is a nurturing and
positive life maybe.

702
00:32:28.470 --> 00:32:31.400
"It could be that thinking
about a successful life

703
00:32:31.400 --> 00:32:33.740
"is almost too much to handle,

704
00:32:33.740 --> 00:32:36.310
"and just as much of a trigger.

705
00:32:36.310 --> 00:32:38.110
"Kristen reflected and worked on her

706
00:32:38.110 --> 00:32:40.028
"countertransference reactions,

707
00:32:40.028 --> 00:32:42.120
"her desire to have Lily make it.

708
00:32:42.120 --> 00:32:43.980
"She started to strategize ideas

709
00:32:43.980 --> 00:32:45.820
"for a different, mutual agreement

710
00:32:45.820 --> 00:32:47.850
"that matched where Lily was.

711
00:32:47.850 --> 00:32:50.360
"A place where she could
help Lily experience

712
00:32:50.360 --> 00:32:52.160
"support and understanding

713
00:32:52.160 --> 00:32:54.260
"for what she needed to discuss,

714
00:32:54.260 --> 00:32:57.230
"mostly the abandonment's and the abuse,

715
00:32:57.230 --> 00:32:59.770
"and her recent trauma.

716
00:32:59.770 --> 00:33:01.730
"Kristen reformulated her thinking

717
00:33:01.730 --> 00:33:03.300
"that helping Lily experience

718
00:33:03.300 --> 00:33:05.730
"a sense of feeling felt

719
00:33:05.730 --> 00:33:07.289
"could be the first step

720
00:33:07.289 --> 00:33:09.810
"towards a new experience of a secure base

721
00:33:09.810 --> 00:33:12.580
"that might help her finish high school.

722
00:33:12.580 --> 00:33:14.450
"Kristen reflected more on the themes

723
00:33:14.450 --> 00:33:16.850
"of Lily's communications.

724
00:33:16.850 --> 00:33:20.040
Lily would acutely feel
a need to do something,

725
00:33:21.050 --> 00:33:24.270
but not have the ability
to do it consistently.

726
00:33:25.100 --> 00:33:27.160
Lily's desire was reawakening

727
00:33:27.160 --> 00:33:29.730
with this relationship with Kristen,

728
00:33:29.730 --> 00:33:33.365
but all too often that
desire had been crushed.

729
00:33:33.365 --> 00:33:35.240
Her hopes had been dashed

730
00:33:35.240 --> 00:33:38.300
most recently with her
aunt and her boyfriends.

731
00:33:38.300 --> 00:33:40.640
So using the facilitation method

732
00:33:40.640 --> 00:33:42.580
helped Kristen in this moment notice,

733
00:33:42.580 --> 00:33:45.950
and reflect on her
countertransference reactions

734
00:33:45.950 --> 00:33:47.150
that were interfering

735
00:33:47.150 --> 00:33:49.780
with her empathy and acceptance,

736
00:33:49.780 --> 00:33:51.620
and also interfering with her ability

737
00:33:51.620 --> 00:33:55.010
to listen more deeply to
Lily's communications,

738
00:33:55.010 --> 00:33:57.020
and not just the literal communication

739
00:33:57.020 --> 00:33:58.580
of what she was saying.

740
00:33:58.580 --> 00:34:01.390
She began to understand Lily's motivation

741
00:34:01.390 --> 00:34:03.730
more differently.

742
00:34:03.730 --> 00:34:06.160
So using the facilitation method

743
00:34:06.160 --> 00:34:07.530
helps a therapist's attention

744
00:34:07.530 --> 00:34:09.800
go to where it needs to.

745
00:34:09.800 --> 00:34:12.940
It guides thinking, zooming in and out

746
00:34:12.940 --> 00:34:14.510
from assessment understanding

747
00:34:14.510 --> 00:34:17.210
to specific moment to clinical process

748
00:34:17.210 --> 00:34:20.050
looking to see if there
are specific conditions,

749
00:34:20.050 --> 00:34:22.880
or relationship processes
that need tending

750
00:34:22.880 --> 00:34:26.850
kind of like Freud's
evenly hovering attention

751
00:34:26.850 --> 00:34:28.690
except this time we're including

752
00:34:28.690 --> 00:34:32.430
a broader, sociocultural,
social network factors,

753
00:34:32.430 --> 00:34:35.030
and not just the client's material.

754
00:34:35.030 --> 00:34:37.720
So I want to shift now to an example

755
00:34:37.720 --> 00:34:40.070
of the need to focus in on

756
00:34:40.070 --> 00:34:43.020
some of the social network factors.

757
00:34:44.370 --> 00:34:47.200
Efrain is a Latino in his 30's.

758
00:34:47.200 --> 00:34:50.340
He's interning at an Elder Care Community.

759
00:34:50.340 --> 00:34:52.350
He prefers to use his nickname "E."

760
00:34:52.350 --> 00:34:55.220
so that's how I will refer to him.

761
00:34:55.220 --> 00:34:56.650
E. focused on problems with

762
00:34:56.650 --> 00:34:58.620
notification procedures between

763
00:34:58.620 --> 00:35:01.150
various departments and staff

764
00:35:01.150 --> 00:35:03.420
at this Elder Care Community.

765
00:35:03.420 --> 00:35:05.760
He decided to work on the
problem himself first,

766
00:35:05.760 --> 00:35:07.630
and then take ideas for broader

767
00:35:07.630 --> 00:35:10.560
organizational change to his supervisor.

768
00:35:10.560 --> 00:35:13.290
E. says: "I first try to
communicate with at least

769
00:35:13.290 --> 00:35:15.540
"one person in each department.

770
00:35:15.540 --> 00:35:18.300
"Housekeeping, laundry,
dietary, maintenance,

771
00:35:18.300 --> 00:35:19.840
"director of nursing.

772
00:35:19.840 --> 00:35:22.170
"After chatting a bit I
would ask something like:

773
00:35:22.170 --> 00:35:24.840
"Hi, are you aware of a room change?

774
00:35:24.840 --> 00:35:26.280
"I found out that many times

775
00:35:26.280 --> 00:35:28.580
"staff were not aware.

776
00:35:28.580 --> 00:35:30.920
"I then decided to attend
the morning meetings

777
00:35:30.920 --> 00:35:32.380
"where all units get discussed

778
00:35:32.380 --> 00:35:34.150
"by the administration department

779
00:35:34.150 --> 00:35:35.490
"with representatives from each

780
00:35:35.490 --> 00:35:37.190
"of the other departments.

781
00:35:37.190 --> 00:35:39.660
"I quickly learned who had what roles,

782
00:35:39.660 --> 00:35:42.100
"and how much power and control they had,

783
00:35:42.100 --> 00:35:45.500
"or at least how far the
power could extend itself.

784
00:35:45.500 --> 00:35:47.110
"The administration department

785
00:35:47.110 --> 00:35:48.770
"would say things like:

786
00:35:48.770 --> 00:35:51.330
"Assisted living has 43 occupancies,

787
00:35:51.330 --> 00:35:53.610
"three vacancies due to medical illness,

788
00:35:53.610 --> 00:35:54.870
"and one discharge to

789
00:35:54.870 --> 00:35:57.610
"the Alzheimer's and Dementia Unit.

790
00:35:57.610 --> 00:35:59.140
"The admin department decides

791
00:35:59.140 --> 00:36:01.250
"which patient is moving where,

792
00:36:01.250 --> 00:36:03.480
"monitors whose left the facility,

793
00:36:03.480 --> 00:36:05.920
"and whose shifting units.

794
00:36:05.920 --> 00:36:07.690
"The administration department rep

795
00:36:07.690 --> 00:36:09.450
"would say things like:

796
00:36:09.450 --> 00:36:11.233
"I've already spoken to the family,

797
00:36:11.233 --> 00:36:12.560
"and the resident about moving

798
00:36:12.560 --> 00:36:14.805
"to the Alzheimer's and Dementia Unit.

799
00:36:14.805 --> 00:36:16.830
"Unfortunately, she's
been falling down a lot,

800
00:36:16.830 --> 00:36:19.300
"and can't remember where the room is.

801
00:36:19.300 --> 00:36:20.600
"She's unable to maintain

802
00:36:20.600 --> 00:36:22.870
"her activities of daily living.

803
00:36:22.870 --> 00:36:24.770
"The family's in agreement
with the room change,

804
00:36:24.770 --> 00:36:26.570
"and Ms. M. understands we would be able

805
00:36:26.570 --> 00:36:28.540
"to keep a closer eye on her.

806
00:36:28.540 --> 00:36:30.380
"She'll be moving today.

807
00:36:30.380 --> 00:36:32.250
"We are looking at Room ABC

808
00:36:32.250 --> 00:36:34.480
"by the window with Ms. K.

809
00:36:34.480 --> 00:36:36.220
"I also have someone coming in tomorrow

810
00:36:36.220 --> 00:36:37.780
"around two who's going to be going

811
00:36:37.780 --> 00:36:40.050
"into Miss M.'s old room.

812
00:36:40.050 --> 00:36:42.080
"The admin department
was calling the shots

813
00:36:42.080 --> 00:36:43.690
"with only minimal input

814
00:36:43.690 --> 00:36:45.650
"from other department heads.

815
00:36:45.650 --> 00:36:48.190
"E. says because I had taken the time

816
00:36:48.190 --> 00:36:50.596
"to get to know workers
in different departments

817
00:36:50.596 --> 00:36:51.800
"I knew that some wouldn't

818
00:36:51.800 --> 00:36:53.470
"know about these changes.

819
00:36:53.470 --> 00:36:54.400
"Even though decisions

820
00:36:54.400 --> 00:36:55.960
"were being made at meetings

821
00:36:55.960 --> 00:36:58.340
"staff who had less
training and authority,

822
00:36:58.340 --> 00:37:00.370
"but ultimately the responsibility

823
00:37:00.370 --> 00:37:02.210
"for preparing rooms for residents

824
00:37:02.210 --> 00:37:05.580
"were often the last to
hear about these decisions.

825
00:37:05.580 --> 00:37:07.580
"So I went to the unit to see how prepared

826
00:37:07.580 --> 00:37:09.450
"they were with the room change.

827
00:37:09.450 --> 00:37:12.350
"I knew Ms. K. was not going to be happy

828
00:37:12.350 --> 00:37:15.390
"about Ms. M. coming into her room.

829
00:37:15.390 --> 00:37:18.030
"On this occasion the
charge nurse was aware,

830
00:37:18.030 --> 00:37:20.190
"but the staff was not.

831
00:37:20.190 --> 00:37:21.630
"The staff member was surprised and said:

832
00:37:21.630 --> 00:37:24.430
"I wish somebody would
have told me about this.

833
00:37:24.430 --> 00:37:26.670
"I don't like being caught off guard,

834
00:37:26.670 --> 00:37:28.510
"so I guess I'm gonna stay around

835
00:37:28.510 --> 00:37:31.000
"because I want to get things ready."

836
00:37:31.000 --> 00:37:33.770
So E. continues: "My goal was to increase

837
00:37:33.770 --> 00:37:35.910
"the collaboration between the departments

838
00:37:35.910 --> 00:37:39.210
"to make sure that the
procedures were supported.

839
00:37:39.210 --> 00:37:41.520
"It's unsettling for a resident

840
00:37:41.520 --> 00:37:43.080
"when the arrival of the resident

841
00:37:43.080 --> 00:37:46.120
"appears to be a surprise.

842
00:37:46.120 --> 00:37:48.390
"Most people don't like surprises.

843
00:37:48.390 --> 00:37:51.660
"They like to be prepared
and have a unified front.

844
00:37:51.660 --> 00:37:53.860
"This also gives the
resident a sense of comfort

845
00:37:53.860 --> 00:37:56.130
"that they will be cared for there.

846
00:37:56.130 --> 00:37:58.590
"It's unsettling for a
resident to hear someone say:

847
00:37:58.590 --> 00:38:00.800
"I didn't know you were coming over here.

848
00:38:00.800 --> 00:38:02.900
"This is their home, it's all they have

849
00:38:02.900 --> 00:38:05.020
"at this point in their lives."

850
00:38:05.810 --> 00:38:07.810
So we've talked so far
about various conditions,

851
00:38:07.810 --> 00:38:09.810
and relationship processes,

852
00:38:09.810 --> 00:38:12.510
and how a clinical social worker uses

853
00:38:12.510 --> 00:38:14.210
the facilitation method

854
00:38:14.210 --> 00:38:16.280
to guide thinking and actions,

855
00:38:16.280 --> 00:38:18.680
but now let's focus on how to decide

856
00:38:18.680 --> 00:38:20.590
what work is optimal now

857
00:38:20.590 --> 00:38:22.800
at any given point in the work.

858
00:38:23.660 --> 00:38:26.300
So first we've already noted

859
00:38:26.300 --> 00:38:29.295
that we're looking our
conditions present or not,

860
00:38:29.295 --> 00:38:31.360
and the first two examples highlighted

861
00:38:31.360 --> 00:38:34.107
the need to cultivate specific conditions,

862
00:38:34.107 --> 00:38:35.700
but now let's say they are,

863
00:38:35.700 --> 00:38:38.080
and your relationship is developing.

864
00:38:39.170 --> 00:38:41.510
So then what you want to think about is

865
00:38:41.510 --> 00:38:43.280
whether you won't need and want to focus

866
00:38:43.280 --> 00:38:46.450
on internal or external actions.

867
00:38:46.450 --> 00:38:48.110
Internal actions are the things

868
00:38:48.110 --> 00:38:50.450
that we're familiar with about insight,

869
00:38:50.450 --> 00:38:53.850
and awareness, understanding,

870
00:38:53.850 --> 00:38:55.690
emotional learning.

871
00:38:55.690 --> 00:38:59.160
External actions focus
on trying out new things.

872
00:38:59.160 --> 00:39:02.660
Can I interact differently
with my partner?

873
00:39:02.660 --> 00:39:04.230
Can I parent my child?

874
00:39:04.230 --> 00:39:07.170
Can I experience being a
parent in a different way

875
00:39:07.170 --> 00:39:10.590
as I'm going with my child
to the park, for example.

876
00:39:12.440 --> 00:39:14.240
So the focus of the work

877
00:39:14.240 --> 00:39:15.700
shifts throughout the work.

878
00:39:15.700 --> 00:39:17.140
You move around.

879
00:39:17.140 --> 00:39:20.410
The top half is focusing
on these conditions,

880
00:39:20.410 --> 00:39:23.550
client, therapist, social network.

881
00:39:23.550 --> 00:39:26.990
The bottom half is where
clients begin to have

882
00:39:26.990 --> 00:39:29.180
these new experiences

883
00:39:29.180 --> 00:39:31.690
through the focus on internal
and external actions.

884
00:39:31.690 --> 00:39:33.090
Those aha moments.

885
00:39:33.090 --> 00:39:35.760
Those moments where things feel different.

886
00:39:35.760 --> 00:39:37.360
"Oh, well it used to be,

887
00:39:37.360 --> 00:39:40.130
"or I used to do, but now."

888
00:39:40.130 --> 00:39:42.870
Those kinds of phrases are examples

889
00:39:42.870 --> 00:39:45.370
of when a client has made a shift,

890
00:39:45.370 --> 00:39:48.190
and moved into a new experience.

891
00:39:51.300 --> 00:39:55.250
And you do this work with
the change strategies.

892
00:39:55.250 --> 00:39:58.720
So they're organized
into three categories.

893
00:39:58.720 --> 00:40:01.490
The ones on the top left are strategies

894
00:40:01.490 --> 00:40:03.220
that tend to happen throughout the work

895
00:40:03.220 --> 00:40:05.002
no matter what we're focusing on.

896
00:40:05.002 --> 00:40:07.430
The ones in the middle group are ones

897
00:40:07.430 --> 00:40:09.860
that generally target internal action,

898
00:40:09.860 --> 00:40:11.730
and the ones on the bottom right

899
00:40:11.730 --> 00:40:14.020
target external action.

900
00:40:14.970 --> 00:40:17.200
Now let's see what some
researchers are saying

901
00:40:17.200 --> 00:40:19.520
about changed strategies.

902
00:40:21.030 --> 00:40:24.610
There seems to be another
set of common factors

903
00:40:24.610 --> 00:40:26.350
that reflects the complexity

904
00:40:26.350 --> 00:40:28.350
of the process of change.

905
00:40:28.350 --> 00:40:30.650
So these are those meta level

906
00:40:30.650 --> 00:40:33.350
transtheoretical processes,

907
00:40:33.350 --> 00:40:36.060
and at the bottom of the slide you see

908
00:40:36.060 --> 00:40:38.590
that the research is challenging

909
00:40:38.590 --> 00:40:39.960
the false dichotomy

910
00:40:39.960 --> 00:40:42.190
that we've tended to have in the field

911
00:40:42.190 --> 00:40:43.800
that technical interventions

912
00:40:43.800 --> 00:40:46.710
are unique to specific approaches,

913
00:40:46.710 --> 00:40:49.600
and that common factors are interpersonal,

914
00:40:49.600 --> 00:40:51.670
and auxiliary to techniques,

915
00:40:51.670 --> 00:40:54.440
or that complimentary or augmenting thing

916
00:40:54.440 --> 00:40:56.560
that SAMHSA would say.

917
00:40:58.880 --> 00:41:00.510
So what do we do?

918
00:41:00.510 --> 00:41:02.650
We know about processes,

919
00:41:02.650 --> 00:41:04.220
and we need to figure out

920
00:41:04.220 --> 00:41:06.890
how to respond in the moment.

921
00:41:06.890 --> 00:41:07.960
So here's where some of

922
00:41:07.960 --> 00:41:10.820
the specific models come into play

923
00:41:10.820 --> 00:41:12.260
because there's many ways

924
00:41:12.260 --> 00:41:15.200
to enact a process.

925
00:41:15.200 --> 00:41:16.260
We have lots of skills,

926
00:41:16.260 --> 00:41:18.470
we have lots of techniques,

927
00:41:18.470 --> 00:41:20.480
and what can be helpful is to think about

928
00:41:20.480 --> 00:41:22.910
the various techniques that you use,

929
00:41:22.910 --> 00:41:26.460
how would they connect up with a process,

930
00:41:26.460 --> 00:41:29.040
but the key thing here is not so much

931
00:41:29.040 --> 00:41:31.350
the what do I say,

932
00:41:31.350 --> 00:41:33.250
but paying attention to how the client,

933
00:41:33.250 --> 00:41:35.810
or family is experiencing,

934
00:41:35.810 --> 00:41:38.620
and participating in these processes,

935
00:41:38.620 --> 00:41:41.950
and that's where we look
at the clinical process

936
00:41:41.950 --> 00:41:44.220
at the moment-by-moment interaction

937
00:41:44.220 --> 00:41:47.680
for evidence about how it is working.

938
00:41:49.430 --> 00:41:50.760
So let's get specific.

939
00:41:50.760 --> 00:41:54.890
One example of a process or change process

940
00:41:54.890 --> 00:41:56.870
is interpersonal learning.

941
00:41:56.870 --> 00:41:59.130
So here are four possible ways

942
00:41:59.130 --> 00:42:03.580
that you might want to enact this process.

943
00:42:03.580 --> 00:42:06.610
You can directly talk about

944
00:42:06.610 --> 00:42:09.580
how a client is experiencing you.

945
00:42:09.580 --> 00:42:11.920
You can talk with a client about

946
00:42:11.920 --> 00:42:15.220
a relationship that they
have with someone else.

947
00:42:15.220 --> 00:42:17.490
You can talk about their expectations

948
00:42:17.490 --> 00:42:19.230
for what they might see.

949
00:42:19.230 --> 00:42:22.400
You can provide particular
psycho-educational

950
00:42:22.400 --> 00:42:24.570
knowledge about relationships,

951
00:42:24.570 --> 00:42:27.100
and we see a lot of that
in parenting groups,

952
00:42:27.100 --> 00:42:29.670
or social skills groups.

953
00:42:29.670 --> 00:42:32.670
So let's return, again,
to Kristen and Lily,

954
00:42:32.670 --> 00:42:34.670
and see how Kristen was facilitating

955
00:42:34.670 --> 00:42:36.760
some interpersonal learning.

956
00:42:37.640 --> 00:42:39.680
She realized that Lily was not ready,

957
00:42:39.680 --> 00:42:42.120
or able to work on changing

958
00:42:42.120 --> 00:42:44.520
her behaviors just yet.

959
00:42:44.520 --> 00:42:47.990
And Kristen also started
noticing some patterns.

960
00:42:47.990 --> 00:42:50.980
Every week Lily would
come and there would be

961
00:42:50.980 --> 00:42:53.360
yet more distress in her life.

962
00:42:53.360 --> 00:42:56.330
Kristen says: "I would
constantly hear her say

963
00:42:56.330 --> 00:42:59.830
"my life is so dramatic, I attract drama.

964
00:42:59.830 --> 00:43:01.967
"So I asked her to think about

965
00:43:01.967 --> 00:43:04.440
"do you think your life
is really dramatic,

966
00:43:04.440 --> 00:43:06.010
"or do you think that you create

967
00:43:06.010 --> 00:43:08.110
"some drama in your life?

968
00:43:08.110 --> 00:43:10.010
"Because I wanted to just test out,

969
00:43:10.010 --> 00:43:12.750
"and see whether she could reflect on

970
00:43:12.750 --> 00:43:13.780
"whether it was something

971
00:43:13.780 --> 00:43:16.350
"that she thought could be changed

972
00:43:16.350 --> 00:43:19.790
"realizing that what was
familiar would also be

973
00:43:19.790 --> 00:43:21.920
"pretty anxiety provoking that these were

974
00:43:21.920 --> 00:43:24.470
"intense reactions she was having."

975
00:43:25.260 --> 00:43:27.560
Well, Kristen says: "She got her answer.

976
00:43:27.560 --> 00:43:31.330
"Lily said that she feels
comfortable and safe

977
00:43:31.330 --> 00:43:32.700
"with the drama in her life.

978
00:43:32.700 --> 00:43:34.900
"She knows what to expect."

979
00:43:34.900 --> 00:43:36.970
So Kristen said: "That queued me into

980
00:43:36.970 --> 00:43:40.218
"the level of anxiety she was feeling

981
00:43:40.218 --> 00:43:43.240
"that Lily was likely
fearful that the next step

982
00:43:43.240 --> 00:43:46.380
"of that relationship
was abandonment or harm

983
00:43:46.380 --> 00:43:49.340
"given what she had
previously experienced.

984
00:43:49.340 --> 00:43:52.163
"Kristen redoubled her efforts to focus

985
00:43:52.163 --> 00:43:56.090
"on providing consistent
care and acceptance

986
00:43:56.090 --> 00:43:59.790
"along with some information
to just let Lily know

987
00:43:59.790 --> 00:44:02.473
"that sometimes drama can feel better

988
00:44:02.473 --> 00:44:03.960
"than that uncertainty

989
00:44:03.960 --> 00:44:06.770
"where you're waiting for
the other shoe to drop.

990
00:44:06.770 --> 00:44:09.570
"Kristen was listening
to see if Lily was able

991
00:44:09.570 --> 00:44:12.170
"to begin to develop a little bit of trust

992
00:44:12.170 --> 00:44:14.970
"in this new experience with her.

993
00:44:14.970 --> 00:44:17.380
"In addition to that Kristen also had

994
00:44:17.380 --> 00:44:20.810
"Lily focus on other
relationships in her life."

995
00:44:20.810 --> 00:44:22.410
Kristen says: "I remember her talking

996
00:44:22.410 --> 00:44:24.180
"about her aunt.

997
00:44:24.180 --> 00:44:26.050
"It was a very conflicted relationship

998
00:44:26.050 --> 00:44:27.920
"because I could hear the animosity,

999
00:44:27.920 --> 00:44:30.120
"and the resentment in Lily's voice,

1000
00:44:30.120 --> 00:44:32.830
"and also hear her passion and love.

1001
00:44:32.830 --> 00:44:35.072
"I listened and tried
to be a sounding board.

1002
00:44:35.072 --> 00:44:37.660
"Lily wanted to tell me about everything.

1003
00:44:37.660 --> 00:44:39.930
"This process helped her begin to reflect

1004
00:44:39.930 --> 00:44:41.100
"on what she had experienced,

1005
00:44:41.100 --> 00:44:43.770
"and started questioning
little bits of it.

1006
00:44:43.770 --> 00:44:46.040
"I remember her saying things like:

1007
00:44:46.040 --> 00:44:49.120
"How could she do that
to me if she loved me?

1008
00:44:49.810 --> 00:44:51.540
"One particular session she just wanted

1009
00:44:51.540 --> 00:44:53.310
"to talk about her mother.

1010
00:44:53.310 --> 00:44:55.450
"She was very emotional and explained how

1011
00:44:55.450 --> 00:44:56.980
"she wanted to get to know her.

1012
00:44:56.980 --> 00:44:58.720
"She didn't know why her mom

1013
00:44:58.720 --> 00:45:00.295
"had abandoned her.

1014
00:45:00.295 --> 00:45:02.450
"She felt a lot of shame.

1015
00:45:02.450 --> 00:45:05.860
"It was clear that Lily's
desire to understand

1016
00:45:05.860 --> 00:45:09.360
"was a deep need to try to appreciate

1017
00:45:09.360 --> 00:45:11.990
"whether she had some part in it

1018
00:45:11.990 --> 00:45:13.330
"that she was feeling

1019
00:45:13.330 --> 00:45:15.880
"a sense of badness about herself."

1020
00:45:17.070 --> 00:45:18.640
Kristen says: "For whatever reason

1021
00:45:18.640 --> 00:45:20.470
"her mom did abandon her.

1022
00:45:20.470 --> 00:45:22.800
"Lily might end up tracking her down,

1023
00:45:22.800 --> 00:45:23.840
"or talking to a relative,

1024
00:45:23.840 --> 00:45:26.310
"or maybe never finding out what happened.

1025
00:45:26.310 --> 00:45:28.980
"What's important now is
to see if Lily can consider

1026
00:45:28.980 --> 00:45:31.020
"that it might not be her fault,

1027
00:45:31.020 --> 00:45:32.380
"that she might not be bad

1028
00:45:32.380 --> 00:45:34.840
"because her mom abandoned her."

1029
00:45:35.450 --> 00:45:39.260
So just to reiterate that the strategies,

1030
00:45:39.260 --> 00:45:42.160
these change processes,

1031
00:45:42.160 --> 00:45:44.860
are organized in terms of
what we want to facilitate

1032
00:45:44.860 --> 00:45:46.090
what we want to have clients

1033
00:45:46.090 --> 00:45:48.280
experience throughout the work.

1034
00:45:48.930 --> 00:45:51.342
One's that focus more on internal actions

1035
00:45:51.342 --> 00:45:54.320
like what I just said as
well as external actions.

1036
00:45:55.570 --> 00:45:57.130
So with Kristen and Lily

1037
00:45:57.130 --> 00:45:59.040
Kristen started with motivation

1038
00:45:59.040 --> 00:46:02.310
concerned about the lack
of hope that Lily had.

1039
00:46:02.310 --> 00:46:04.640
She then noted the need to address

1040
00:46:04.640 --> 00:46:06.890
her own countertransference reactions

1041
00:46:06.890 --> 00:46:09.580
that were interfering with her empathy,

1042
00:46:09.580 --> 00:46:13.460
and then she shifted
into areas of developing

1043
00:46:13.460 --> 00:46:15.900
resources through the relationship

1044
00:46:15.900 --> 00:46:17.290
of Kristen and Lily

1045
00:46:17.290 --> 00:46:19.950
as well as working on
interpersonal learning.

1046
00:46:22.030 --> 00:46:24.070
So as you're going through the work

1047
00:46:24.070 --> 00:46:25.400
the facilitation method

1048
00:46:25.400 --> 00:46:27.540
is what one uses in the moment

1049
00:46:27.540 --> 00:46:31.910
when one is stuck and
guides your thinking,

1050
00:46:31.910 --> 00:46:33.470
but now let's talk for a couple of minutes

1051
00:46:33.470 --> 00:46:36.210
about who you work with.

1052
00:46:36.210 --> 00:46:39.010
So, yes, individuals and family clients,

1053
00:46:39.010 --> 00:46:42.670
or groups of clients is a common decision,

1054
00:46:44.100 --> 00:46:46.730
but we also seek out professionals,

1055
00:46:46.730 --> 00:46:48.660
or para-professionals who are also

1056
00:46:48.660 --> 00:46:50.750
influencing the work.

1057
00:46:51.920 --> 00:46:54.570
So here's an example of that.

1058
00:46:54.570 --> 00:46:56.640
Steven, an Italian American male

1059
00:46:56.640 --> 00:46:59.040
in his mid 20's is interning at an

1060
00:46:59.040 --> 00:47:01.670
Early Childhood Development Center.

1061
00:47:01.670 --> 00:47:06.280
Steven says: "Paul Kivel
poses this question.

1062
00:47:06.280 --> 00:47:08.456
"Are you willing to speak truth to power

1063
00:47:08.456 --> 00:47:12.200
"even at the risk of your
job by certain agencies?"

1064
00:47:14.120 --> 00:47:16.760
Steven says: "I wanted
to report two teachers

1065
00:47:16.760 --> 00:47:19.060
"that were negatively treating a child

1066
00:47:19.060 --> 00:47:20.590
"just about everyday the child

1067
00:47:20.590 --> 00:47:21.890
"was there at the center.

1068
00:47:21.890 --> 00:47:23.810
"They would pick on him, make fun of him,

1069
00:47:23.810 --> 00:47:25.670
"and make him susceptible to teasing

1070
00:47:25.670 --> 00:47:29.270
"due to the nature of their
discipline strategies.

1071
00:47:29.270 --> 00:47:30.700
"The risk that I ended up taking

1072
00:47:30.700 --> 00:47:32.540
"was talking with the director

1073
00:47:32.540 --> 00:47:34.740
"about the teacher's behaviors.

1074
00:47:34.740 --> 00:47:36.110
"This was still challenging

1075
00:47:36.110 --> 00:47:38.180
"because the director was barely involved

1076
00:47:38.180 --> 00:47:40.910
"with what was going on in the classrooms.

1077
00:47:40.910 --> 00:47:43.180
"Instead of angerly
pointing out to the director

1078
00:47:43.180 --> 00:47:44.990
"that she was not doing her job,

1079
00:47:44.990 --> 00:47:47.220
"which is what I wanted to say,

1080
00:47:47.220 --> 00:47:49.460
"I talked to her about what I had observed

1081
00:47:49.460 --> 00:47:50.990
"hoping that this would motivate her

1082
00:47:50.990 --> 00:47:52.760
"to become more involved.

1083
00:47:52.760 --> 00:47:53.890
"I respectfully asked that

1084
00:47:53.890 --> 00:47:56.907
"she come spend some
time in these classrooms

1085
00:47:56.907 --> 00:47:59.060
"just to get a feel for what was going on,

1086
00:47:59.060 --> 00:48:01.030
"and understand better.

1087
00:48:01.030 --> 00:48:05.200
"She hesitantly obliged
and did set up the times.

1088
00:48:05.200 --> 00:48:07.410
"After sitting in on the classrooms

1089
00:48:07.410 --> 00:48:09.340
"the director asked my supervisor and I

1090
00:48:09.340 --> 00:48:12.080
"to respond by working with the teachers.

1091
00:48:12.080 --> 00:48:15.050
"Apparently the risk I took by asking her

1092
00:48:15.050 --> 00:48:17.220
"to take some time to
spend in the classrooms

1093
00:48:17.220 --> 00:48:20.090
"paid off and it did raise her awareness.

1094
00:48:20.090 --> 00:48:21.820
"She said she wanted
the children to be able

1095
00:48:21.820 --> 00:48:23.590
"to learn from their mistakes,

1096
00:48:23.590 --> 00:48:25.790
"not just to be disciplined.

1097
00:48:25.790 --> 00:48:28.530
"So my supervisor and I set about

1098
00:48:28.530 --> 00:48:30.430
"to schedule times with the teachers

1099
00:48:30.430 --> 00:48:31.930
"where we could have them share

1100
00:48:31.930 --> 00:48:34.200
"their concerns and frustrations,

1101
00:48:34.200 --> 00:48:36.570
"but then also say that we had some

1102
00:48:36.570 --> 00:48:39.000
"additional ideas that we
thought might be useful,

1103
00:48:39.000 --> 00:48:40.770
"and might make it a little bit easier

1104
00:48:40.770 --> 00:48:43.190
"on the stress that they were feeling.

1105
00:48:43.880 --> 00:48:45.410
"We wanted to convey to the teachers

1106
00:48:45.410 --> 00:48:47.340
"that we were on their side.

1107
00:48:47.340 --> 00:48:48.980
"We wanted to hear their needs,

1108
00:48:48.980 --> 00:48:51.280
"and that we had ideas
that might be helpful

1109
00:48:51.280 --> 00:48:54.390
"to them as well as to the students.

1110
00:48:54.390 --> 00:48:57.060
"In subsequent meetings we discussed ways

1111
00:48:57.060 --> 00:48:59.150
"that positive reinforcement strategies

1112
00:48:59.150 --> 00:49:01.030
"could be instituted with the children

1113
00:49:01.030 --> 00:49:02.775
"in their classrooms.

1114
00:49:02.775 --> 00:49:04.490
"The actions worked.

1115
00:49:04.490 --> 00:49:07.400
"My supervisor and I gave them tools.

1116
00:49:07.400 --> 00:49:10.530
"In turn, it provided more
support for the teachers,

1117
00:49:10.530 --> 00:49:13.240
"and the students were able to learn

1118
00:49:13.240 --> 00:49:16.410
"from what was going on in the classrooms.

1119
00:49:16.410 --> 00:49:18.680
"It was a big risk for me to take

1120
00:49:18.680 --> 00:49:19.910
"to speak with the director

1121
00:49:19.910 --> 00:49:22.210
"because of her position of power.

1122
00:49:22.210 --> 00:49:25.550
"I was hesitant, but with
my supervisor's support

1123
00:49:25.550 --> 00:49:27.490
"it felt great to find a way to interact

1124
00:49:27.490 --> 00:49:29.092
"that engaged the director

1125
00:49:29.092 --> 00:49:31.190
"that really turned around the way

1126
00:49:31.190 --> 00:49:33.640
"that the development
center was functioning."

1127
00:49:36.030 --> 00:49:38.460
So with the ongoing work then

1128
00:49:38.460 --> 00:49:40.700
you are going to shift back and forth

1129
00:49:40.700 --> 00:49:43.981
noticing about whether
you need to circle back

1130
00:49:43.981 --> 00:49:46.970
if someone begins to get discouraged,

1131
00:49:46.970 --> 00:49:48.740
and feeling a little bit down

1132
00:49:48.740 --> 00:49:51.010
about the lack of progress with the work.

1133
00:49:51.010 --> 00:49:53.510
If you need to work on
some of your own reactions.

1134
00:49:53.510 --> 00:49:56.820
If you're noticing barriers
within your organization

1135
00:49:56.820 --> 00:49:59.130
that need to have a response.

1136
00:50:00.690 --> 00:50:02.420
And, again, the focus of the work

1137
00:50:02.420 --> 00:50:05.990
shifts back and forth
around in these areas.

1138
00:50:05.990 --> 00:50:09.640
So last piece on Kristen and Lily.

1139
00:50:11.600 --> 00:50:15.450
Despite missing 90 days
of school during the year

1140
00:50:16.700 --> 00:50:18.640
Lily would consistently come to school

1141
00:50:18.640 --> 00:50:19.840
on the days that she had

1142
00:50:19.840 --> 00:50:22.010
her appointments with Kristen.

1143
00:50:22.010 --> 00:50:24.092
Kristen says:

1144
00:50:24.092 --> 00:50:27.390
"That after Lily was attending

1145
00:50:27.390 --> 00:50:29.620
"weekly sessions for five months

1146
00:50:29.620 --> 00:50:32.580
"she decided to try an alternative school

1147
00:50:32.580 --> 00:50:36.120
"so she was out of this
school for a month.

1148
00:50:36.120 --> 00:50:38.660
"Lily ended up coming back

1149
00:50:38.660 --> 00:50:42.040
"one month before Kristen
ended her internship.

1150
00:50:42.040 --> 00:50:43.760
"The first day that Lily came back

1151
00:50:43.760 --> 00:50:46.570
"she came right to Kristen's office,

1152
00:50:46.570 --> 00:50:48.610
"and Kristen hoped it meant that she had

1153
00:50:48.610 --> 00:50:50.973
"experienced a little bit of caring,

1154
00:50:50.973 --> 00:50:54.180
"and felt that it was real for her,

1155
00:50:54.180 --> 00:50:56.220
"but at the same time Lily
was still having trouble

1156
00:50:56.220 --> 00:50:58.010
"focusing on school.

1157
00:50:58.010 --> 00:50:59.690
"As we wrapped up our work Lily said

1158
00:50:59.690 --> 00:51:00.842
"her main goal was to get

1159
00:51:00.842 --> 00:51:03.050
"her high school diploma next year,

1160
00:51:03.050 --> 00:51:04.210
"but it was still hard for her

1161
00:51:04.210 --> 00:51:06.130
"to make it to school everyday.

1162
00:51:06.130 --> 00:51:08.130
"Things felt so tenuous.

1163
00:51:08.130 --> 00:51:11.030
"One step forward, two steps back.

1164
00:51:11.030 --> 00:51:12.360
"Kristen was concerned that

1165
00:51:12.360 --> 00:51:13.900
"the social support conditions

1166
00:51:13.900 --> 00:51:16.070
"were not sufficiently in place for her

1167
00:51:16.070 --> 00:51:18.410
"to attend high school regularly.

1168
00:51:18.410 --> 00:51:21.902
"Because of this and her
lack of friends, overall,

1169
00:51:21.902 --> 00:51:24.740
"as Kristen prepared to
end her work with Lily

1170
00:51:24.740 --> 00:51:26.133
"she focused on connecting her

1171
00:51:26.133 --> 00:51:29.220
"with both peer and adult resources.

1172
00:51:29.220 --> 00:51:31.280
"One resource was the after school group

1173
00:51:31.280 --> 00:51:33.790
"that Kristen was co-facilitating called:

1174
00:51:33.790 --> 00:51:36.440
"Career Beginnings, and this was a group

1175
00:51:36.440 --> 00:51:38.790
"for college bound juniors and seniors

1176
00:51:38.790 --> 00:51:40.450
"to meet and learn about how to apply

1177
00:51:40.450 --> 00:51:42.860
"for financial aid and scholarships,

1178
00:51:42.860 --> 00:51:45.630
"writing the essays, et cetera.

1179
00:51:45.630 --> 00:51:47.770
"So Lily was able to come
to one of those groups

1180
00:51:47.770 --> 00:51:49.930
"before Kristen left

1181
00:51:49.930 --> 00:51:52.490
"when Kristen was co-facilitating it,

1182
00:51:52.490 --> 00:51:54.761
"and Lily also agreed to continue to meet

1183
00:51:54.761 --> 00:51:57.300
"with Kristen's supervisor."

1184
00:51:57.300 --> 00:51:58.830
Kristen says: "We seemed to have created

1185
00:51:58.830 --> 00:52:00.310
"a bit of a holding environment

1186
00:52:00.310 --> 00:52:02.010
"for Lily at the school.

1187
00:52:02.010 --> 00:52:03.440
"I hope she will be able

1188
00:52:03.440 --> 00:52:06.340
"to use these supports after I leave."

1189
00:52:07.780 --> 00:52:10.810
So two final things before we wrap up.

1190
00:52:12.290 --> 00:52:14.220
Let's talk about where we are currently

1191
00:52:14.220 --> 00:52:16.280
about the research on change.

1192
00:52:16.280 --> 00:52:19.550
So we continue to see
studies that provide support

1193
00:52:19.550 --> 00:52:22.740
for thinking about change as this complex,

1194
00:52:22.740 --> 00:52:26.090
dynamic interaction of multiple factors.

1195
00:52:26.090 --> 00:52:29.800
More specifically we're
starting to have some

1196
00:52:29.800 --> 00:52:31.340
of the active ingredients,

1197
00:52:31.340 --> 00:52:33.230
and some specific treatments

1198
00:52:33.230 --> 00:52:35.720
being questioned through dismantling

1199
00:52:35.720 --> 00:52:38.690
our component analysis studies.

1200
00:52:39.440 --> 00:52:43.210
So, for example, in some CBT studies

1201
00:52:43.210 --> 00:52:46.420
they're finding that a
focus on early attachment

1202
00:52:46.420 --> 00:52:48.600
or relationship dynamics

1203
00:52:48.600 --> 00:52:51.990
were also some of the key ingredients

1204
00:52:51.990 --> 00:52:55.010
that positively influenced change.

1205
00:52:56.570 --> 00:52:59.860
So while the current theories of change

1206
00:52:59.860 --> 00:53:02.410
such as CBT aren't wrong

1207
00:53:02.410 --> 00:53:04.710
we know that CBT theories

1208
00:53:04.710 --> 00:53:07.380
do focus more on cognition,

1209
00:53:07.380 --> 00:53:09.180
a little bit less on relationship,

1210
00:53:09.180 --> 00:53:11.410
a little bit less on emotion.

1211
00:53:11.410 --> 00:53:14.380
What we're finding is that
the active ingredients

1212
00:53:14.380 --> 00:53:15.910
that we thought were active

1213
00:53:15.910 --> 00:53:17.690
in a particular theory

1214
00:53:17.690 --> 00:53:20.750
might not capture the full complexity

1215
00:53:20.750 --> 00:53:22.600
of what's going on.

1216
00:53:22.600 --> 00:53:25.170
So what this means then
is that even though

1217
00:53:25.170 --> 00:53:28.034
specific techniques are being used

1218
00:53:28.034 --> 00:53:29.760
with a particular model,

1219
00:53:29.760 --> 00:53:33.040
other processes and
activities are also happening,

1220
00:53:33.040 --> 00:53:36.380
and influencing the outcomes.

1221
00:53:36.380 --> 00:53:38.810
So there seems to be more going on

1222
00:53:38.810 --> 00:53:41.740
than what research has named for us.

1223
00:53:41.740 --> 00:53:45.400
This dovetails with
the continued interest,

1224
00:53:45.400 --> 00:53:47.150
and research on common factors

1225
00:53:47.150 --> 00:53:48.790
that we're seeing across

1226
00:53:48.790 --> 00:53:50.990
various treatment modalities.

1227
00:53:50.990 --> 00:53:53.590
So in psycho-dynamic
research, for example,

1228
00:53:53.590 --> 00:53:55.620
Peter Fonagy is beginning to talk

1229
00:53:55.620 --> 00:53:58.130
about mentalization as perhaps

1230
00:53:58.130 --> 00:54:01.133
functioning as a common factor

1231
00:54:01.133 --> 00:54:03.769
as a way of establishing trust,

1232
00:54:03.769 --> 00:54:06.518
and then openness to something new.

1233
00:54:07.170 --> 00:54:09.210
We see interesting common factors

1234
00:54:09.210 --> 00:54:12.940
in work with co-occurring disorders.

1235
00:54:12.940 --> 00:54:16.080
Within CBT there's been a study

1236
00:54:16.080 --> 00:54:19.967
that is looking at the
commonalities across CBT's.

1237
00:54:20.685 --> 00:54:22.480
Within marriage and family therapy

1238
00:54:22.480 --> 00:54:24.960
we know there's a lot of
work that has been done

1239
00:54:24.960 --> 00:54:27.020
on integrative work,

1240
00:54:27.020 --> 00:54:29.220
and also in the child therapies.

1241
00:54:29.220 --> 00:54:31.420
Chorpita, for example, has been working on

1242
00:54:31.420 --> 00:54:34.460
common elements that are the basis for

1243
00:54:34.460 --> 00:54:36.216
the majority of the child therapy

1244
00:54:36.216 --> 00:54:38.443
models and protocols.

1245
00:54:40.110 --> 00:54:43.940
So to conclude the Common Factors model

1246
00:54:43.940 --> 00:54:47.880
for me has been an organizing scaffold.

1247
00:54:47.880 --> 00:54:51.850
It's been a way for me to
be able to use evidence

1248
00:54:51.850 --> 00:54:54.610
to draw on and to respond to some

1249
00:54:54.610 --> 00:54:56.220
of the contemporary challenges

1250
00:54:56.220 --> 00:54:57.980
that I outlined earlier,

1251
00:54:57.980 --> 00:55:02.040
so it helps understand how change place,

1252
00:55:02.040 --> 00:55:04.460
and it also helps guide thinking around

1253
00:55:04.460 --> 00:55:06.770
making decisions in the moment,

1254
00:55:06.770 --> 00:55:08.850
and overall with clients.

1255
00:55:10.430 --> 00:55:11.800
Thank you.

1256
00:55:11.800 --> 00:55:13.760
(applause)

1257
00:55:24.910 --> 00:55:27.850
So Dr. Drisko tells me that there's time

1258
00:55:27.850 --> 00:55:30.330
for some questions if anyone has anything.

1259
00:55:47.690 --> 00:55:50.760
- [Voiceover] I'd like to
know where I can get more.

1260
00:55:50.760 --> 00:55:52.920
If I read your

1261
00:55:54.450 --> 00:55:56.350
published article where do you get

1262
00:55:56.350 --> 00:55:58.991
more of this in detail and depth?

1263
00:56:00.140 --> 00:56:04.260
- Yes, and the model itself

1264
00:56:04.260 --> 00:56:07.489
is the book that's published by Pearson,

1265
00:56:07.489 --> 00:56:11.360
so a lot of the slides about method,

1266
00:56:11.360 --> 00:56:14.980
and the factors and how to think about it.

1267
00:56:16.540 --> 00:56:19.720
So you let me just do a
little PR on the book, huh?

1268
00:56:19.720 --> 00:56:21.430
Thank you Charlotte.

1269
00:56:21.430 --> 00:56:23.810
- [Voiceover] I'll get to
follow up with your book.

1270
00:56:23.810 --> 00:56:25.930
- Okay, thank you.

1271
00:56:30.020 --> 00:56:30.880
Elizabeth.

1272
00:56:30.880 --> 00:56:32.750
- [Elizabeth] Yes, can you
talk a little bit about

1273
00:56:32.750 --> 00:56:36.260
for new social work students

1274
00:56:36.260 --> 00:56:38.150
how you would see and review

1275
00:56:38.150 --> 00:56:39.460
clients for the first time

1276
00:56:39.460 --> 00:56:41.730
how you would begin to talk to them

1277
00:56:41.730 --> 00:56:43.660
about the Common Factor model.

1278
00:56:43.660 --> 00:56:45.520
They're struggling with "Oh my God,

1279
00:56:45.520 --> 00:56:47.300
"I'm seeing a plan for the first time."

1280
00:56:47.300 --> 00:56:50.220
and they're writing about these.

1281
00:56:50.220 --> 00:56:52.400
For them new models, new ideas,

1282
00:56:52.400 --> 00:56:53.810
new way of thinking,

1283
00:56:53.810 --> 00:56:55.510
so how do you begin to integrate?

1284
00:56:55.510 --> 00:56:57.140
You talked about your student E.

1285
00:56:57.140 --> 00:56:59.210
Maybe you could talk a little bit about

1286
00:56:59.210 --> 00:57:00.340
how did the two come together?

1287
00:57:00.340 --> 00:57:04.360
As a professor how do you
help to bridge the two?

1288
00:57:06.290 --> 00:57:08.830
- I think, you know, just with many other

1289
00:57:08.830 --> 00:57:11.920
beginning practice it's engagement,

1290
00:57:11.920 --> 00:57:14.780
it's relationship, it's listening.

1291
00:57:16.860 --> 00:57:18.755
I think for me the other piece

1292
00:57:18.755 --> 00:57:22.063
that I emphasize a lot is really tuning in

1293
00:57:22.063 --> 00:57:26.320
to where the client is
with energy and ability

1294
00:57:26.320 --> 00:57:27.900
to engage with the work

1295
00:57:27.900 --> 00:57:29.640
what we might call "motivation."

1296
00:57:29.640 --> 00:57:32.380
So there's often a lot of distress,

1297
00:57:32.380 --> 00:57:33.550
but sometimes they're distressed

1298
00:57:33.550 --> 00:57:35.910
because somebody else sent them there,

1299
00:57:35.910 --> 00:57:38.610
or there's distress, but
maybe not the ability,

1300
00:57:38.610 --> 00:57:41.260
or the energy to do
much about it right now,

1301
00:57:41.260 --> 00:57:44.560
and needing a lot of holding and support.

1302
00:57:46.850 --> 00:57:50.830
The facilitation method I say is:

1303
00:57:50.830 --> 00:57:52.160
"Talk to the hand," you know,

1304
00:57:52.160 --> 00:57:54.818
because it's five things,
and so I really say:

1305
00:57:54.818 --> 00:57:56.380
"What did you just hear?"

1306
00:57:56.380 --> 00:57:58.470
And reflect on that, you know,

1307
00:57:58.470 --> 00:58:00.370
"What did you notice?"

1308
00:58:00.370 --> 00:58:02.480
And so you made that suggestion.

1309
00:58:02.480 --> 00:58:04.740
Did the person go do it?

1310
00:58:04.740 --> 00:58:07.010
And why do you think not?

1311
00:58:07.010 --> 00:58:10.110
So a lot of things that
folks here in the room

1312
00:58:10.110 --> 00:58:12.410
who've been psycho-dynamically trained

1313
00:58:12.410 --> 00:58:15.320
would say: "Well, yeah,
that's kind of what we do."

1314
00:58:15.320 --> 00:58:18.330
It's similar to, I think, what holds up

1315
00:58:18.330 --> 00:58:20.125
with Common Factors

1316
00:58:20.125 --> 00:58:21.920
because the relationship,

1317
00:58:21.920 --> 00:58:25.230
and the client and therapist
factors are so key here

1318
00:58:25.230 --> 00:58:28.370
which really is the heart
of psycho-dynamic work

1319
00:58:28.370 --> 00:58:31.500
as well so it's really not getting too far

1320
00:58:31.500 --> 00:58:35.700
ahead of where the client
is of really listening.

1321
00:58:37.110 --> 00:58:38.640
- [Voiceover] What does the broad

1322
00:58:38.640 --> 00:58:41.040
case conceptualization look like?

1323
00:58:41.040 --> 00:58:41.880
How is it different from

1324
00:58:41.880 --> 00:58:44.370
the regular case conceptualization?

1325
00:58:44.940 --> 00:58:47.290
- In terms of conceptualizing a problem,

1326
00:58:47.290 --> 00:58:50.284
or a diagnosis it would not differ.

1327
00:58:50.284 --> 00:58:52.520
I think this is more additive.

1328
00:58:52.520 --> 00:58:55.990
So when I was saying that
one wants to listen for

1329
00:58:55.990 --> 00:58:59.280
what's the capacity for change

1330
00:58:59.280 --> 00:59:02.730
that one writes up

1331
00:59:02.730 --> 00:59:04.200
what one notices about

1332
00:59:04.200 --> 00:59:07.270
the conditions that are sufficiently,

1333
00:59:07.270 --> 00:59:09.730
or insufficiently present,

1334
00:59:09.730 --> 00:59:12.240
and some of that could be some of what

1335
00:59:12.240 --> 00:59:13.904
we do in a psychosocial around

1336
00:59:13.904 --> 00:59:16.340
a client's social supports

1337
00:59:16.340 --> 00:59:18.180
would fall into some of that,

1338
00:59:18.180 --> 00:59:22.010
but I think there'd be more attention paid

1339
00:59:22.010 --> 00:59:26.050
onto where the client
factors are, for example.

1340
00:59:26.050 --> 00:59:28.130
I'm not sure how much of

1341
00:59:28.130 --> 00:59:30.460
a broad conceptualization thinks about

1342
00:59:30.460 --> 00:59:34.200
distress and hope and active help seeking,

1343
00:59:34.200 --> 00:59:37.500
and whether a client thinks that therapy

1344
00:59:37.500 --> 00:59:39.730
is something that's credible or compatible

1345
00:59:39.730 --> 00:59:42.330
with one's belief system.

1346
00:59:42.330 --> 00:59:45.710
I think some of that is in addition to

1347
00:59:45.710 --> 00:59:47.240
a case conceptualization.

1348
00:59:47.240 --> 00:59:48.504
- [Voiceover] So if I hear you correctly

1349
00:59:48.504 --> 00:59:50.350
you're saying that client expectations

1350
00:59:50.350 --> 00:59:53.510
need to be addressed as well as the role

1351
00:59:53.510 --> 00:59:56.302
of Common Factor.

1352
00:59:56.302 --> 00:59:58.780
You also talked about motivation

1353
00:59:58.780 --> 00:59:59.962
as one of the key factors,

1354
00:59:59.962 --> 01:00:03.060
but is it according to the
demoralization hypothesis

1355
01:00:03.060 --> 01:00:05.220
hope that's going to go around?

1356
01:00:05.220 --> 01:00:06.700
I mean you're making it one (mumbles)

1357
01:00:06.700 --> 01:00:08.910
Is that like a broad piece?

1358
01:00:10.840 --> 01:00:12.479
- Let me see if I'm following you right.

1359
01:00:12.479 --> 01:00:15.380
Motivation is kind of
the big umbrella concept,

1360
01:00:15.380 --> 01:00:17.380
and distress and hope,

1361
01:00:17.380 --> 01:00:20.340
and beliefs and expectancy

1362
01:00:20.340 --> 01:00:23.510
are all like underneath that umbrella

1363
01:00:23.510 --> 01:00:24.710
like pieces of.

1364
01:00:24.710 --> 01:00:26.190
- [Voiceover] Many people kind of try

1365
01:00:26.190 --> 01:00:28.120
to make so many strands out of it,

1366
01:00:28.120 --> 01:00:29.510
and there's so many factors,

1367
01:00:29.510 --> 01:00:31.720
and you know that even Common Factors,

1368
01:00:31.720 --> 01:00:34.120
there are like now 35 Common Factors.

1369
01:00:34.120 --> 01:00:35.530
In terms of integrated theories

1370
01:00:35.530 --> 01:00:37.730
there are probably 100
integrated theories,

1371
01:00:37.730 --> 01:00:39.955
so where are we going ahead with this?

1372
01:00:39.955 --> 01:00:42.570
We started with 400 therapies,

1373
01:00:42.570 --> 01:00:43.600
and we said, you know what,

1374
01:00:43.600 --> 01:00:44.870
maybe there are Common Factors,

1375
01:00:44.870 --> 01:00:47.370
so where do you need the Common Factors?

1376
01:00:47.370 --> 01:00:48.610
Once we have the Common Factors

1377
01:00:48.610 --> 01:00:50.380
now we try to combine the Common Factors

1378
01:00:50.380 --> 01:00:52.463
in so many ways to have another theory.

1379
01:00:52.463 --> 01:00:53.980
So where are we going with this,

1380
01:00:53.980 --> 01:00:56.740
and why should social work embrace it?

1381
01:00:56.740 --> 01:00:58.530
- That's an excellent question.

1382
01:00:58.530 --> 01:01:01.450
So for me, again, it's not about the list.

1383
01:01:01.450 --> 01:01:02.710
Yeah-no, I mean when I was

1384
01:01:02.710 --> 01:01:03.850
at dinner with Dr. Drisko

1385
01:01:03.850 --> 01:01:07.020
I was just talking about
the self-study we did

1386
01:01:07.020 --> 01:01:09.920
for re-accreditation and
the 42 practice behaviors

1387
01:01:09.920 --> 01:01:11.490
that drove me crazy.

1388
01:01:11.490 --> 01:01:12.590
Yeah, so I get it.

1389
01:01:12.590 --> 01:01:15.060
So for me it's not about a laundry list

1390
01:01:15.060 --> 01:01:16.500
that I'm going down going

1391
01:01:16.500 --> 01:01:18.210
check, check, check, check, check,

1392
01:01:18.210 --> 01:01:21.305
but rather it's thinking about

1393
01:01:21.305 --> 01:01:24.300
from the client perspective

1394
01:01:24.300 --> 01:01:26.760
Lily was distressed,

1395
01:01:28.110 --> 01:01:32.010
but she really did not have hope

1396
01:01:32.010 --> 01:01:33.626
that things could be different,

1397
01:01:33.626 --> 01:01:37.490
so she would come in and
just arrive, right, okay?

1398
01:01:37.490 --> 01:01:39.590
So one doesn't necessarily
have to think about

1399
01:01:39.590 --> 01:01:41.563
each of these separately,

1400
01:01:41.563 --> 01:01:43.490
but what it does though is ...

1401
01:01:43.490 --> 01:01:45.220
For me anyway,

1402
01:01:45.220 --> 01:01:47.294
is thinking about not just

1403
01:01:47.294 --> 01:01:49.370
problem or diagnosis,

1404
01:01:49.370 --> 01:01:53.670
but for me it flips it
to capacity for change.

1405
01:01:53.670 --> 01:01:57.440
It flips thinking into moving forward.

1406
01:01:57.440 --> 01:01:59.040
What do we have?

1407
01:01:59.040 --> 01:02:01.450
What is already there
that I want to support,

1408
01:02:01.450 --> 01:02:02.770
and build on?

1409
01:02:02.770 --> 01:02:05.099
What might be missing
that is such a barrier

1410
01:02:05.099 --> 01:02:07.050
that absolutely nothing's gonna happen

1411
01:02:07.050 --> 01:02:08.690
until we look at this.

1412
01:02:08.690 --> 01:02:10.480
So that's kind of how I deal with it.

1413
01:02:10.480 --> 01:02:11.830
- [Voiceover] So what I hear is, again,

1414
01:02:11.830 --> 01:02:15.070
we are kind of locating
the problem in the client

1415
01:02:15.660 --> 01:02:18.260
saying there's no capacity for change,

1416
01:02:18.260 --> 01:02:19.730
or there's no hope,

1417
01:02:19.730 --> 01:02:23.230
but is this a bit of shift
from looking at the problem

1418
01:02:23.230 --> 01:02:24.540
(mumbles) the client,

1419
01:02:24.540 --> 01:02:26.508
and then working on it.

1420
01:02:26.508 --> 01:02:28.870
Isn't that our role as social workers?

1421
01:02:28.870 --> 01:02:31.303
- It sure is, so I just zoomed into some

1422
01:02:31.303 --> 01:02:32.640
client factors right there,

1423
01:02:32.640 --> 01:02:34.170
but that's why there are therapists,

1424
01:02:34.170 --> 01:02:35.450
and social network factors.

1425
01:02:35.450 --> 01:02:37.910
My examples, the teachers

1426
01:02:37.910 --> 01:02:40.750
in the Child Development Center, right?

1427
01:02:40.750 --> 01:02:42.990
And the lack of collaboration

1428
01:02:42.990 --> 01:02:44.950
within the Elder Care Community,

1429
01:02:44.950 --> 01:02:46.730
and the countertransference reactions

1430
01:02:46.730 --> 01:02:49.790
within the therapists are all conditions

1431
01:02:49.790 --> 01:02:51.500
that needed to be identified with

1432
01:02:51.500 --> 01:02:53.850
the facilitation method, you know,

1433
01:02:53.850 --> 01:02:55.286
of noticing in the moment,

1434
01:02:55.286 --> 01:02:58.795
and needed a response so that the client

1435
01:02:58.795 --> 01:03:00.163
would not get blamed,

1436
01:03:00.163 --> 01:03:03.113
so that it's not a blame
the victim kind of thing.

1437
01:03:03.113 --> 01:03:05.100
So for me it helps hold out

1438
01:03:05.100 --> 01:03:08.784
the full spectrum of conditions

1439
01:03:08.784 --> 01:03:11.090
that all influence the work

1440
01:03:12.210 --> 01:03:13.740
with the method kind of trying

1441
01:03:13.740 --> 01:03:16.130
to keep your attention roaming,

1442
01:03:17.410 --> 01:03:21.090
and noticing when something over here

1443
01:03:21.090 --> 01:03:22.485
is what really needs to be addressed

1444
01:03:22.485 --> 01:03:25.020
in the organization or
within the community,

1445
01:03:25.020 --> 01:03:27.423
or a policy, for example.

1446
01:03:27.423 --> 01:03:29.720
Something that's oppressive,

1447
01:03:29.720 --> 01:03:31.310
an oppressive practice.

1448
01:03:31.310 --> 01:03:32.940
Because I think you're absolutely right,

1449
01:03:32.940 --> 01:03:36.142
that that's what I've been
trying to work towards

1450
01:03:36.142 --> 01:03:38.490
in conceptualizing it this way.

1451
01:03:39.833 --> 01:03:41.530
Yeah, Brian.

1452
01:03:42.640 --> 01:03:44.450
- [Brian] I'm assuming
that you teach this model

1453
01:03:44.450 --> 01:03:47.520
to both BSW and MSW students,

1454
01:03:47.520 --> 01:03:48.950
and when you do that I'm kind of curious

1455
01:03:48.950 --> 01:03:52.740
how you tease out kind
of a scope of practice

1456
01:03:52.740 --> 01:03:56.200
with that for those different levels?

1457
01:03:58.860 --> 01:04:01.890
- Are you thinking about
undergrad or grad more

1458
01:04:01.890 --> 01:04:03.800
just so I know where
you're headed with this.

1459
01:04:03.800 --> 01:04:05.200
- [Brian] What I'm
thinking was the problem

1460
01:04:05.200 --> 01:04:08.740
we have back home where
hospital administrators

1461
01:04:08.740 --> 01:04:11.110
are saying: "L"et's just hire these BSW's

1462
01:04:11.110 --> 01:04:12.700
"because from my perspective

1463
01:04:12.700 --> 01:04:14.910
"they appear to be doing the same thing

1464
01:04:14.910 --> 01:04:16.270
"that MSW's are doing.

1465
01:04:16.270 --> 01:04:17.600
"I can't tell the difference."

1466
01:04:17.600 --> 01:04:19.440
Help me understand the difference.

1467
01:04:19.440 --> 01:04:23.010
That's what these non-social
work administrators

1468
01:04:23.010 --> 01:04:24.150
who like to save dollars

1469
01:04:24.150 --> 01:04:27.720
are saying about the scope of practice.

1470
01:04:27.720 --> 01:04:29.560
So that's why I'm kind of curious.

1471
01:04:29.560 --> 01:04:32.690
How that gets teased out

1472
01:04:32.690 --> 01:04:36.070
when we have a model like this

1473
01:04:36.070 --> 01:04:37.900
that's this broad.

1474
01:04:37.900 --> 01:04:40.620
- Okay, well first of all
in Connecticut, anyway,

1475
01:04:40.620 --> 01:04:42.360
we have the reverse problem

1476
01:04:42.360 --> 01:04:45.240
where most people don't
want to hire BSW's.

1477
01:04:45.240 --> 01:04:47.990
They want the MSW's that can get licensed,

1478
01:04:47.990 --> 01:04:50.860
and do third party reimbursement,

1479
01:04:52.700 --> 01:04:56.360
but having said that let's
stay with your question.

1480
01:05:00.160 --> 01:05:03.500
Well, I'm gonna toot my own horn here.

1481
01:05:03.500 --> 01:05:06.700
In the clinical Social Work Journal

1482
01:05:06.700 --> 01:05:09.400
the final article in the
special issue is called:

1483
01:05:09.400 --> 01:05:11.160
"From Silos to Scaffolding."

1484
01:05:11.160 --> 01:05:14.040
In there Dr. Grady and I write about

1485
01:05:14.040 --> 01:05:16.446
how we envision Common Factors

1486
01:05:16.446 --> 01:05:20.310
as the scaffold to which you put

1487
01:05:20.310 --> 01:05:22.720
specified treatments,

1488
01:05:22.720 --> 01:05:25.640
so if you've got these
processed strategies

1489
01:05:25.640 --> 01:05:29.190
you can think about how DBT, for example,

1490
01:05:29.190 --> 01:05:31.780
or EMDR, whatever,

1491
01:05:31.780 --> 01:05:34.680
are more specific versions

1492
01:05:34.680 --> 01:05:38.060
of interpersonal learning, right?

1493
01:05:38.060 --> 01:05:40.570
Or practice and reinforcement.

1494
01:05:41.600 --> 01:05:45.640
And so it's still keeping this idea

1495
01:05:45.640 --> 01:05:48.430
of capacity and how we're moving

1496
01:05:48.430 --> 01:05:49.680
forward with change,

1497
01:05:49.680 --> 01:05:53.170
and then it's inserting on
top a particular treatment

1498
01:05:53.170 --> 01:05:55.880
that might be indicated
or might be pretty useful

1499
01:05:55.880 --> 01:05:58.810
because it gives you some clearer guidance

1500
01:05:58.810 --> 01:06:01.600
for a particular diagnosis or a particular

1501
01:06:03.870 --> 01:06:05.120
psychosocial problem,

1502
01:06:05.120 --> 01:06:07.990
so that's kind of where I situate it,

1503
01:06:07.990 --> 01:06:10.400
so I view Common Factors as kind of

1504
01:06:10.400 --> 01:06:13.570
a solid foundation and
in many ways it can work,

1505
01:06:13.570 --> 01:06:15.270
and I think it can work in the absence

1506
01:06:15.270 --> 01:06:17.680
of more specified things,

1507
01:06:17.680 --> 01:06:18.770
but then we certainly know

1508
01:06:18.770 --> 01:06:21.670
we've got perfectly good
practice models identified

1509
01:06:21.670 --> 01:06:25.373
that I think could be wired in

1510
01:06:25.373 --> 01:06:27.480
with just some thinking about how

1511
01:06:27.480 --> 01:06:30.260
they're more specific examples.

1512
01:06:32.240 --> 01:06:34.980
- [Voiceover] I'm curious what are

1513
01:06:34.980 --> 01:06:37.290
the things that worry you about, like,

1514
01:06:37.290 --> 01:06:40.520
what keeps you up at night
about these problems?

1515
01:06:40.520 --> 01:06:42.790
Like, where are the areas
where you're thinking

1516
01:06:42.790 --> 01:06:45.200
oh I haven't quite know that downer.

1517
01:06:45.200 --> 01:06:47.130
It can't be how does scaffolding needs

1518
01:06:47.130 --> 01:06:48.460
adds to the house

1519
01:06:48.460 --> 01:06:50.530
because it's like the doghouse right now,

1520
01:06:50.530 --> 01:06:52.890
or does not play in there.

1521
01:06:55.430 --> 01:06:56.280
If you know what I mean?

1522
01:06:56.280 --> 01:07:00.380
- I do, there's not
enough on social action.

1523
01:07:00.380 --> 01:07:04.910
We've got one lone advocacies process.

1524
01:07:09.280 --> 01:07:12.680
So it's not even close to the house.

1525
01:07:14.390 --> 01:07:15.960
That's a great question, yeah,

1526
01:07:15.960 --> 01:07:18.730
so for it truly to, I think,

1527
01:07:18.730 --> 01:07:21.665
represent social work in all its fullness,

1528
01:07:21.665 --> 01:07:23.230
yeah, it needs more of that.

1529
01:07:23.230 --> 01:07:25.830
I think what it's helped with is

1530
01:07:25.830 --> 01:07:28.210
organizational practice

1531
01:07:28.210 --> 01:07:31.970
thinking about the
social workers policies,

1532
01:07:31.970 --> 01:07:35.600
procedures, funding sources.

1533
01:07:38.430 --> 01:07:41.980
It really identifies
so much of what we find

1534
01:07:41.980 --> 01:07:43.950
challenging and problematic is

1535
01:07:43.950 --> 01:07:46.280
we practice in the field,

1536
01:07:46.280 --> 01:07:48.510
but it doesn't get to social change

1537
01:07:48.510 --> 01:07:51.310
in the way that I think that it needs to.

1538
01:07:55.126 --> 01:07:56.458
- [Voiceover] It's an annoying question,

1539
01:07:56.458 --> 01:07:58.630
so my apologies at the outset.

1540
01:07:58.630 --> 01:07:59.870
I was wondering how is it

1541
01:07:59.870 --> 01:08:02.060
that your conceptualizing change

1542
01:08:02.060 --> 01:08:04.130
within this model?

1543
01:08:12.690 --> 01:08:14.590
- I think, you know, it's kind of

1544
01:08:14.590 --> 01:08:17.830
all of Bronfenbrenner, it's ecological.

1545
01:08:18.980 --> 01:08:21.210
So that would be another area,

1546
01:08:21.210 --> 01:08:24.290
so for people who want
to go do more research

1547
01:08:24.290 --> 01:08:26.170
who want to nail it down more,

1548
01:08:26.170 --> 01:08:27.790
and get more specific

1549
01:08:27.790 --> 01:08:31.050
I think that's where the work needs to be,

1550
01:08:31.670 --> 01:08:34.150
so it's general.

1551
01:08:34.780 --> 01:08:37.570
Conditions and processes they interact,

1552
01:08:37.570 --> 01:08:39.460
and they produce change.

1553
01:08:41.120 --> 01:08:43.474
Castonguay, for example,

1554
01:08:43.474 --> 01:08:45.054
has been highlighting for us.

1555
01:08:45.054 --> 01:08:46.814
Some of the surprises we're finding,

1556
01:08:46.814 --> 01:08:48.620
and there's a ton of research

1557
01:08:48.620 --> 01:08:50.410
that still needs to be done to say

1558
01:08:50.410 --> 01:08:53.563
well, if this, then this,
and under this condition,

1559
01:08:53.563 --> 01:08:55.680
and then we get this, right?

1560
01:08:56.660 --> 01:08:58.700
Well, there's about five more decades

1561
01:08:58.700 --> 01:09:00.960
of research right there, right?

1562
01:09:00.960 --> 01:09:02.697
Do you want to do it?

1563
01:09:10.607 --> 01:09:11.730
- [Voiceover] I think some of these topics

1564
01:09:11.730 --> 01:09:12.903
have been really interesting

1565
01:09:12.903 --> 01:09:16.720
because they point to how complicated

1566
01:09:16.720 --> 01:09:20.313
change in human beings and systems are,

1567
01:09:21.190 --> 01:09:23.660
and a lot of what you're
pointing out, I think,

1568
01:09:23.660 --> 01:09:25.630
is something that we've got to give

1569
01:09:25.630 --> 01:09:29.710
Ms. Keenan credit for and Mark Cameron.

1570
01:09:29.710 --> 01:09:32.840
These models were
developed by psychologists,

1571
01:09:33.660 --> 01:09:36.630
and they really focused on process,

1572
01:09:36.630 --> 01:09:39.330
and therapist variables,

1573
01:09:39.330 --> 01:09:42.340
and they almost left
the client down with it.

1574
01:09:42.340 --> 01:09:43.761
One of the things that's kind of obvious

1575
01:09:43.761 --> 01:09:46.470
when you bring a social work perspective

1576
01:09:46.470 --> 01:09:50.050
is that the client brings a lot too.

1577
01:09:50.050 --> 01:09:53.130
This process doesn't
happen by itself, right?

1578
01:09:53.130 --> 01:09:55.460
And then you get into not only that,

1579
01:09:55.460 --> 01:09:56.620
but as you were saying

1580
01:09:56.620 --> 01:10:00.410
who supports the social
worker doing the work,

1581
01:10:00.410 --> 01:10:03.230
and what kinds of thing happen

1582
01:10:03.230 --> 01:10:06.290
that are kind of in the dance?

1583
01:10:06.290 --> 01:10:08.500
Can the client get to the agency?

1584
01:10:08.500 --> 01:10:09.760
All the kind of stuff that we know,

1585
01:10:09.760 --> 01:10:11.290
and so forth, those matters,

1586
01:10:11.290 --> 01:10:14.350
and life functions,
and policy and payment.

1587
01:10:16.740 --> 01:10:18.140
There's just so much out there

1588
01:10:18.140 --> 01:10:19.672
that how you put it together,

1589
01:10:19.672 --> 01:10:21.570
and how you think about it

1590
01:10:21.570 --> 01:10:24.490
is incredibly complicated,

1591
01:10:24.490 --> 01:10:27.560
and to make the model allow for more

1592
01:10:28.284 --> 01:10:31.860
variations is actually
part of what we have to do

1593
01:10:31.860 --> 01:10:33.850
which in some ways makes the model

1594
01:10:33.850 --> 01:10:35.580
seem more difficult,

1595
01:10:35.580 --> 01:10:38.420
but it maybe gets a little
closer to real life,

1596
01:10:38.420 --> 01:10:40.790
and I think that's what
you and Dr. Cameron

1597
01:10:40.790 --> 01:10:42.730
have been trying to do.

1598
01:10:42.730 --> 01:10:45.470
- [Voiceover] Professor,
I have a question for you.

1599
01:10:47.140 --> 01:10:50.072
If this model, like you say,

1600
01:10:50.072 --> 01:10:51.700
was developed by psychologists

1601
01:10:51.700 --> 01:10:55.310
and it focuses more on
the therapist variables,

1602
01:10:55.310 --> 01:10:57.150
and the process variables

1603
01:10:57.150 --> 01:10:59.966
do you think it's a good model,

1604
01:10:59.966 --> 01:11:01.910
and it seems more-so just for

1605
01:11:01.910 --> 01:11:04.590
micro practice kind of a thing.

1606
01:11:04.590 --> 01:11:06.485
Do you think it's a good model

1607
01:11:06.485 --> 01:11:09.280
for social worker embrace
and go ahead with?

1608
01:11:13.170 --> 01:11:14.890
I don't know.

1609
01:11:14.890 --> 01:11:17.170
- Well, just to clarify.

1610
01:11:17.170 --> 01:11:20.760
The research that identifies
some of the factors

1611
01:11:21.660 --> 01:11:24.440
comes largely from psychologists,

1612
01:11:24.440 --> 01:11:27.840
and then what Dr. Drisko has added,

1613
01:11:27.840 --> 01:11:31.080
and in our own research

1614
01:11:31.080 --> 01:11:32.920
we have included social workers

1615
01:11:32.920 --> 01:11:34.320
who have done research

1616
01:11:34.320 --> 01:11:36.120
that focus in on some of these

1617
01:11:36.120 --> 01:11:37.950
social network factors,

1618
01:11:37.950 --> 01:11:40.490
that look at a little bit more about

1619
01:11:40.490 --> 01:11:42.974
material resources and the impact

1620
01:11:42.974 --> 01:11:45.160
of various social supports,

1621
01:11:45.160 --> 01:11:48.820
for example, on a family.

1622
01:11:50.000 --> 01:11:52.460
So putting that together

1623
01:11:52.460 --> 01:11:55.720
you're right that I
think the model fits best

1624
01:11:56.600 --> 01:11:58.560
with direct practice,

1625
01:11:58.560 --> 01:12:01.040
so work with individuals,
or families, or groups,

1626
01:12:01.040 --> 01:12:04.290
practice within communities,
within organizations.

1627
01:12:05.300 --> 01:12:08.945
And as I was saying to this other woman

1628
01:12:08.945 --> 01:12:11.890
I would look and do look for other models

1629
01:12:11.890 --> 01:12:14.290
for social change.

1630
01:12:14.290 --> 01:12:16.150
I can use a lot of these ideas.

1631
01:12:16.150 --> 01:12:19.490
I can still look to see
and listen for capacity.

1632
01:12:19.490 --> 01:12:22.193
I can look to see what
conditions are missing,

1633
01:12:22.193 --> 01:12:25.170
and then I'm just taking categories,

1634
01:12:25.170 --> 01:12:27.700
and just shifting and applying.

1635
01:12:29.630 --> 01:12:32.650
And, you know, this may not play out.

1636
01:12:32.650 --> 01:12:34.450
It may not end up being useful,

1637
01:12:34.450 --> 01:12:37.120
and so we'll keep looking, right? Yeah.

1638
01:12:39.970 --> 01:12:42.550
- [Voiceover] I'm not sure if I fully

1639
01:12:42.550 --> 01:12:43.370
form this question,

1640
01:12:43.370 --> 01:12:44.260
but I'm gonna try it anyway

1641
01:12:44.260 --> 01:12:46.320
which is so a lot of this

1642
01:12:46.320 --> 01:12:48.510
is sort of a kind board

1643
01:12:48.510 --> 01:12:50.940
that warrants motivation and expectancy

1644
01:12:50.940 --> 01:12:52.290
and hope within the client.

1645
01:12:52.290 --> 01:12:54.830
I'm wondering whether you have any advice,

1646
01:12:54.830 --> 01:12:56.527
especially for new clinicians,

1647
01:12:56.527 --> 01:12:59.630
to figure out is there
any information about ways

1648
01:12:59.630 --> 01:13:02.031
in which unintentionally the way

1649
01:13:02.031 --> 01:13:03.870
in which you assess hope within

1650
01:13:03.870 --> 01:13:07.880
the therapeutic communication

1651
01:13:07.880 --> 01:13:09.450
when you are actually impeding

1652
01:13:09.450 --> 01:13:11.020
the client's ability to fully

1653
01:13:11.020 --> 01:13:13.901
assess that within themselves

1654
01:13:13.901 --> 01:13:16.150
depending on if you have a checklist

1655
01:13:16.150 --> 01:13:18.513
when they come in, one to 10,

1656
01:13:18.513 --> 01:13:20.990
or the way you ask the question, or ...

1657
01:13:20.990 --> 01:13:22.570
- Well, you've got it.

1658
01:13:23.353 --> 01:13:26.180
You just gave yourself the response

1659
01:13:26.180 --> 01:13:30.430
I was gonna say is usually checklists,

1660
01:13:30.430 --> 01:13:32.850
and structured assessments

1661
01:13:33.844 --> 01:13:36.700
are not gonna be as useful.

1662
01:13:36.700 --> 01:13:39.434
More open-ended questions

1663
01:13:39.434 --> 01:13:41.800
asking about times in the past

1664
01:13:41.800 --> 01:13:43.780
when they've encountered a challenge,

1665
01:13:43.780 --> 01:13:46.973
and how did they respond,
how did it happen?

1666
01:13:46.973 --> 01:13:49.711
Did it seem workable for them?

1667
01:13:49.711 --> 01:13:52.280
So hearing stories about
previous experiences,

1668
01:13:52.280 --> 01:13:54.519
asking what they think

1669
01:13:54.519 --> 01:13:56.770
is gonna happen in the future.

1670
01:13:58.000 --> 01:14:00.630
And you're right, so
it's more like engaging

1671
01:14:00.630 --> 01:14:02.290
in a conversation with them

1672
01:14:02.290 --> 01:14:04.830
about what troubles them,

1673
01:14:04.830 --> 01:14:07.142
what keeps them awake at night,

1674
01:14:07.142 --> 01:14:10.010
and do they think it can be different,

1675
01:14:10.010 --> 01:14:12.190
and what would it take?

1676
01:14:13.070 --> 01:14:15.920
Yeah, that's a great question.

1677
01:14:25.890 --> 01:14:27.640
Are we good?

1678
01:14:28.050 --> 01:14:29.790
All right, thanks so much everyone.

1679
01:14:29.790 --> 01:14:31.890
(applause)