Moving from Supportive to Solution Focused Brief Therapy Interventions

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome everybody to today's presentation on moving from supportive to solution focused interventions. And this is one of those things that is really kind of timely, I guess. I mean, usually it's timely, but right now there are a lot of people struggling with a lot of stress and supportive interventions can only go so far. And helping them deal with this stress in the long term will require that they start moving towards solution focused interventions. So we're going to differentiate between supportive and solution focused interventions, identify the function of each, and explore some techniques or interventions to facilitate transition from supportive to problem solving or solution focused interventions. So what's the difference? Supportive interventions are grounded in empathy and helping the person survive the moment. Such is kind of like plugging a hole in the hull of a ship until you can get to port. It is not a permanent solution. It's supposed to help you kind of get your bearings again. Supportive interventions can be thought of as ventilation and validation. This is when people are expressing themselves. We're validating how they feel. We're not looking at solutions, we are just helping them feel validated. We are using empathy. It's that really Rogerian humanistic approach. Solution focused interventions aim to help the person move from surviving the moment to thriving. We're going to help them repair the ship, so to speak, and figure out how to avoid the reef the next time. We're going to have public health crises in the future. Every single year we have the flu. And the flu kills tens of thousands of people every year. And that's something that we know when the flu happens, when something else happens, when there's another epidemic, we're going to have to be prepared. And solution focused interventions help people develop those tools. So the next time there's a problem, they say, oh, okay, I know what I need to do to deal with this. I know what's within my control and I know which parts are not within my control in supportive interventions. They are great. This is where we start out when people come into our office, when we meet people on the street. However you're engaging with people, the first thing we're going to do is establish rapport and validate their feelings. Their feelings are how they feel. And some people may be reacting to this more strongly than others based on their feelings, phenomenological reality based on their history, their history of exposure to pandemics, their history of exposure to viruses. Maybe you're working with somebody whose grandmother passed away from the flu a few years ago. Maybe you're working with somebody who's had the flu and been hospitalized with it. So they are extremely stressed right now. Maybe you're working with somebody who's never had the flu or never had it badly, but they have some underlying conditions and they know they're in that high risk group right now. There are a lot of different things just related to this particular health crisis right now, which is kind of what we're focusing on today, that can cause people to feel a fair amount of anxiety. We also want to recognize there are other feelings out there, not only anxiety, but there's a lot of anger. There's a lot of anger out there because we don't have control over this. When this situation, when any situation happens that is outside of our control, we have that sense of fight or flee. And sometimes we have both feelings all at once. We want to run away from it, but we're also really ticked off, really angry that the situation's occurring. We're angry that it's disrupting our life. We're angry that we don't know more than we do. Unfortunately, some of that just can't be controlled. This is a, in the case of coronavirus, this is a new thing. And it's not like, you know, we've had 20, 30, 40, 50 years, however long the flu has been around. I think it's been around for over 100 years to get information, to learn how it behaves and how to prevent it. So, yes, I understand anger. Anger is a natural response to a threat. We want to fight or flee. However, anger and anxiety in any of your stress feelings also rev up that HPA axis, that threat response system, and reduce your immune system. We don't want people reducing their immune system right now. So we want to validate their feelings and go, you know what? I get it. You feel how you feel and this is why your body is telling you to fight or flee, because there's a threat. I get it. And based on your past, I get it. Another thing that may affect people's feelings right now is if we start going into periods where we are under mandatory quarantine, or people who are under mandatory quarantine may feel trapped. And if they have a history of trauma in which they felt trapped before, maybe it was a domestically violent relationship, maybe it was abusive situation, There are a lot of different situations where somebody may have felt trapped and Felt like they were powerless over their life. And in some ways, we are losing a little bit of control over our life right now as restaurants are closing, as stores are closing, as we're being told that we're supposed to basically self isolate. And some people that may trigger memories of a time in their past when they actually had less control. Now they have control. They have the ability to say, okay, I'm gonna stay inside because it's safe. But being told that they have to, being told that they can't go out may trigger some trauma reactions in some people that maybe they didn't even notice was there. The supportive interventions are designed to help people return to their baseline or return to their wise mind. Supportive interventions are the things that we can use to help people turn down that HPA axis so they can get that adrenaline out of the way, so they can think more clearly, so they can be mindful of the moment, evaluate their options, and choose the next best response to, to help them live a rich and meaningful life. So supportive interventions that we're going to use include active listening, you know, our basic counseling 101. Let's empathize, validate, and let people ventilate. Sometimes we just need to get stuff out, you know, have somebody hear it, get it out of our head. The next one we can use is radical acceptance. Helping people develop that attitude of it is what it is. I can't necessarily change it right now. It is what it is. Once we accept life as it is in the moment, we accept without judgment, our feelings, then we can move on to distress tolerance and using some of those skills that Linehan identified that can help us cope with the situation. Some of the distress tolerance skills we may use include activities, sometimes sitting around the house watching the news. 247 is not the best solution to the particular issue. And it's going to be important for people to identify ways when they start feeling anxious that they can deal with those feelings so they don't stay stuck in that feeling of anxiety. Why do people get stuck? Well, supportive interventions are like removing boiling rice from a hot stove. And I. Every time I make rice, I don't know what my malfunction is. It doesn't matter how big of a pot I use, every time I make rice, I end up having some of it boil over and make a mess. So. So this is a particularly poignant example for me. When the rice starts to boil, it often boils over. You know, the heat is there. So we remove the rice from the heat and the bubbles go down because it Makes an awful mess when it gets all over the stovetop. Alright, that is akin to a supportive intervention. We are allowing people's stress that's bubbling over to go down. We're allowing them to ventilate and we're validating how they feel. Let them get back down to where they're not feeling like they're bubbling over. Unfortunately, with rice, the rice still needs to cook, which is akin to the problem still being there. Even though the immediate crisis of the rice boiling over, that's gone. We still have the current issues that we're dealing with. So what do we do? The cook, if we're talking about the rice, the cook returns the rice to the stove. What's going to happen? As soon as that rice and that heat connect again, it's going to start boiling over unless we have figured out a solution to the problem. And that's really what we're looking for. As soon as somebody turns on the news again, as soon as somebody is out in public and sees somebody else sneeze, as soon as the heat is turned back on, as soon as they're feeling a threat again, those emotions may bubble up unless they have tools to deal with them. What we want to do, we want to help people identify the problem. Exactly what is it that is causing your distress right now? And we want to identify are you feeling anxious about the virus? Are you feeling anxious about your finances because you're not able to go to work right now? Are you feeling overwhelmed because your kids have been home for three weeks? What feelings are you feeling and why? You know, let's start looking at what, what the problems are. Let's identify what your hoped for resolution of the problem would be. What would this look like if you could turn down your anxiety one notch? Maybe not completely down, but what would it look like if we could turn it down one notch? How have you solved similar problems in the past? You know, when your kids have been on summer break, when you're, or, you know, maybe there's been a snowstorm and the schools are suddenly closed and you can't leave the house and you're stuck in the house for a week or two weeks. You know, sometimes it happens in places where it snows or after a hurricane. There are times where we may be sort of stuck at house, stuck in the house. How have you handled that before? What are exceptions to the situation? If somebody is anxious because they think, you know, everybody is getting sick or everybody is having this problem, or nobody is safe, let's look for exceptions. Who has it who doesn't have it, who's getting sick versus who's not getting sick, who's at risk versus who's not at risk and making sure people realize that there are exceptions. You know, how can you be one of the exceptions? If you are practicing social distancing, if you are washing your hands, if you are wiping down doorknobs, light switches and mobile devices with regularity, you're probably engaging those behaviors. So you are not getting exposed as much. That's one exception. If you are of a certain age group, you know that 10 to 39, I think they're saying it is for Covid, then you are in a low risk group. If you have no underlying health conditions, then you are in a low risk group. So having people really look at the difference between the probability and the possibility. Yes. Is there a possibility that the worst could happen? Uh huh. There's always a possibility. But what is the probability that it's going to happen or for you? Solution Focused interventions help people develop a plan, but they require a clear head and the ability to concentrate. We are not good at making plans. We are not good at seeing the forest for the trees when we are in an adrenaline haze. It is really important to, to help people validate and ventilate so they can get into their wise mind, get into a clear head, really look at the facts and the options. In order for them to get to this place, a lot of times they have to feel heard and understood by other people. They need to feel like, you know, somebody gets it and it requires that they have motivation to make a change. They need to understand what, what is within their control and what is actually going to be helpful. What is it that I can do to help me achieve my goal of staying healthy, happy and all that stuff. One of the things that we can do with people is help them walk through a decisional balance exercise. And it is very simple. You create four quadrants. One side is to keep treading water, which is having the person ventilate, validate, you know, go through that. They leave your office, they really don't have any more tools than they had when they came in. So the next time they get upset, guess what? They come back and they have to ventilate and get validation again. What are the benefits to that? And have them identify if there are any, what are the drawbacks to that? And you know, see my mind goes to the drawbacks to ventilation and validation being the only tool we use that you're going to have to keep doing it over and over Again, kind of like trying to get that rice to cook, but every time you return it to the heat, it starts to boil over. You got to pick it up, let the bubbles go down, put it back on and try to get it through. It's a very, very inefficient process, trust me. On the other hand, the benefits to finding permanent solutions, the benefits to developing tools to deal with this anxiety. The benefits include not having to repeat the cycle of boiling over. You know, hopefully you don't get to the point where you're boiling over because you can mitigate that ahead of time. Encourage people to look at the benefits. Some people get stuck on in ventilation and validation because sometimes they're afraid to move forward, they're afraid to try different tools. We want to look at what is keeping people from being willing to develop new tools if they are. How can we help people maintain motivation during this time? We let them come in and we talk with them or we talk with them on video chat. We let them ventilate. We validate their feelings. We start helping them identify particular steps they can take, particular solutions that they might explore. How do we keep them motivated? Use assignments between sessions to keep people on task. Like daily mindfulness activities to help them stay on task or cognitive processing therapy. Use the challenging questions worksheet and encourage them to use that twice a day. If you're going to have them focus on the positive for 20 minutes a day, that's another thing. They can journal for 20 minutes a day about the things that are going right in their world. Have them do daily check ins and complete a problem log. You know, that's again a mindfulness activity. They check in with themselves. They identify what's weighing on their mind and potentially ideally identify two solutions to each of those problems that they can consider. We want to use scaffolding to help them develop a game plan. Scaffolding is being there, supporting them and encouraging them up until the point they need help. People don't necessarily need help at the very beginning. They may be able to get all the way to a certain point. Think about if you ever taught your kids how to tie their shoes. You start out, you've got to do everything for them, and then they get to the point where they can cross the laces and do the first tie. So you don't want to help them with that, but then they get stuck scaffolding. You step in as soon as they get stuck, stuck, and you say, okay, now what's the next step? And you coach them the rest of the way. With scaffolding, people gradually develop those skills. We want to help them develop a game plan and use scaffolding to use these new skills. So if they're coming back and they're saying, you know, I still had a lot of anxiety this week, we say, okay, let's take a look at what happened. Tell me about some situations where you felt anxious. What were your thoughts and what did you do now? How could you have, what other solutions could you have used to address that anxiety? So we're brainstorming now. All right, now, next time, when you feel this way, how can you remind yourself to use these skills that we just talked about? We want to provide reinforcement for successful completion of tasks. We want to highlight their improvements. They may not be feeling, yippee, skippy. This is a time right now of a lot of ambiguity, a lot of anxiety. I'm not expecting people to go through the entire week feeling like they are on top of the world. But I also don't want them going through the entire week feeling completely powerless and hopeless and helpless. So it's going to be important to have them keep a journal or a log that identifies on a scale of one to four, one being horrible and five being on top of the world or four being on top of the world. You know, give them some verbal anchor points how they're feeling each morning and each evening so they can see, you know, on a scale how they're feeling in general. We want them to start feeling, you know, ideally threes or fours if you want to use a five point scale. Threes or fours, I'm not expecting fives, but we want to see them on a general, on an average daily basis, feeling okay. We want to help them avoid backsliding by rewarding the behaviors that they do. We want to help them see how those behaviors are helpful and encourage them to reward themselves. And we want to consider all factors that may enhance or impede motivation emotionally. If they are depressed, they're probably going to lack a lot of motivation. What can we do to help them emotionally enhance their motivation? One of the ways is helping them identify, okay, this thing that I'm supposed to do, this skill, this tool, this activity, how is it going to make me happier? How is it going to help me feel happier or less anxious? If they can understand that if they do X, then they're going to feel better, that may encourage them to do X mentally. How is it logical that if I do this, I will feel better and I'll be able to concentrate more physically if I do this? Activity. If I do these things, if I practice this, these solutions that we've talked about, how is it going to improve my sleep? How is it going to improve my pain? Remember, when our HPA axis is activated, serotonin goes down, pain threshold also goes down. If people are reducing their stress, they're going to sleep better, they're going to have higher immune system and a higher pain threshold. All of those are wonderful things. Interpersonally, who can be there to encourage me to do these things? Who can be there to remind me to do these things? Whenever we start doing something new, we do need to be reminded. We do need the prompts. And occupationally, you know, how could this improve? If I start doing this and handling my anxiety or dealing with my anger, how will this improve my productivity at work or at school? A lot of people are having to work remotely right now and we're going to need to help them figure out how to adjust their environment so they can be productive at work or at school. Remember that everything we do serves some sort of a purpose and is generally more rewarding than the alternative. So if clients keep doing things, if clients keep coming back and they are anxious, if clients keep coming back and they are angry and they're not engaging solutions, then we want to say, what's the benefit to them of not engaging these solutions? Or what are we missing? We may be trying to address something. Maybe we think their anxiety has to do with catching the virus when in actuality their anxiety has to do with losing their house because they haven't been able to work for two weeks or, you know, we need to figure out what we're missing. Why does Sally seem to shut down or. Yes, but any suggestions? If we're talking in a session and we start talking about solution focused options and Sal, every time we throw an option out, Sally says, yeah, but you know, I've done that before, it didn't work. Yeah, but okay, so instead of giving her things, instead of throwing things at her, say, why don't you reach into your mental banks and tell me what solutions have worked for you in the past and then let's talk about how they might work in the future and maybe how to try those out. Why does John insist on watching the news all day long even though he knows it'll stress him out? Maybe for John, that's how he has some sense of control. He's hoping he's going to hear something that's just going to turn his world around and make him happy. And he keeps listening and he keeps hoping and it just his hopes keep getting dashed and he keeps hearing the same crisis stuff over and over again. So we want to look at what is the benefit or what is John hoping the benefit is going to be of watching the news all day long. And what might be a more helpful solution? Cognitive processing can help therapists identify and address cognitive distortions. We do want to look at that over generalization, the all or nothing thinking and the jumping to conclusions, making assumptions without having all of the facts. There's a lot of information out there and it's really important that people have all of the facts and have those facts in context. I'll just stick with the flu since we have that every single year and we know that it is more dangerous for very young children and older people. The facts are, you know, if you're in one of those two groups, you are at higher risk. If you are not in one of those two groups, then you are at much lower risk. We want to address emotional reasoning. Sometimes people feel scared partly because everybody around them is just oozing panic and oozing stress and fear. So they're like, oh, well, they're feeling fearful. Then, you know, it's almost contagious. If they're feeling fearful, then I must feel fearful. Therefore I need to figure out a reason to feel fearful. That's emotional reasoning. We are finding data to support our fear instead of letting the data guide our feelings. We want to help people make sure that they are using facts if they start to feel fearful or if they start to feel angry. Okay, accept it is what it is. Now, what can I do to address this situation in the moment? And part of that may involve getting the facts and comparing, making sure we're not confusing possibility with probability. We also want to help people identify faulty goal setting and problem solving skills. Right now, if people expect to be super happy, yippee skippy, every single day, they are going to set themselves up for failure. What is a goal right now? To stay relatively calm and content, to keep our immune system up and to get through this short period knowing that in a couple of months, hopefully things will start resuming. Normal cognitive processing can help clients gain a different perspective if they are thinking of things in terms of emotional reasoning. If we help them switch gears over to facts, it can give them a different perspective. It can help identify clients, identify what parts are within their control, and set smart goals and increase their sense of efficacy, increase their sense that, okay, if I do this, if I wash my hands, I'm staying safer. If I, you know, clean My phone and door handles and light switches, I am stopping the spread of the disease, at least in my household. Okay. These are things that I can do. These are proactive steps that I can take that do make a difference. When we're working with cognitive processing, have the person problem by problem. You know, you want to do this one problem at a time. Tell me the problem. What are the facts for and against your belief about the problem? So if people are concerned that, you know, it is a bad flu season and they are afraid that they're going to get the flu and die from it, or their child is going to get the flu and die from it, okay, you know, that is a thought they're having, and it is what it is. Now let's look at the facts. How likely are you or your child to get the flu and die from it based on what you're doing right now to protect yourself? I know. What was it two years ago when we had such a wickedly bad flu season? I was terrified because my daughter has underlying lung issues and whenever she gets sick and almost always goes to bronchitis or pneumonia, and I was terrified she was going to get it. What did I do? Thankfully, I was very thankful at that point. She was homeschooled and she got her flu shot, and we were practicing safety precautions and things. Staying upset, staying worried about it, would have done zero good. However, using that anxiety that I felt to say, okay, you need to make some changes during this flu season to make sure that your daughter stays healthy. So what needs to happen? And that anxiety, that norepinephrine that was being dumped by my HPA axis, said, all right, let's get focused on using our energy to do things that will help solve this problem or prevent it from being a problem. Have people identify what other factors and people are involved. What other things do we need to consider? If you are not going out of your house, then you're probably not going to contact the virus. There are a lot of factors to be considered. Are you assuming things about other people or the future? Are you assuming that? For example, I know the stock market has been all over the place, and there's a lot of people that are, you know, in their 40s, 50s, some in their 30s, who are especially fiscally minded, that are seeing their retirement just disappear and in just huge chunks at a time, and they may be freaking out, assuming that that's not going to come back, the stock market's not going to come back, that their retirement is gone, they're going to have to Work forever. We want to look at those cognitions and say, what are the facts? What do we know? We can't worry about the future because we can't control the future. We have no idea what's going to happen three hours from now, let alone three months from now. Encouraging people to take proactive, practical steps in the present to control the situation as much as they can, and that's as good as we can get. Make sure they're not confusing possibility with probability. You know, there's a possibility that just about anything could happen. What's the probability that it is going to happen to you today? That it's going to happen to you? Ever Help people focus on the parts of the situation that they control and which parts they can't Using a bunch of energy. Getting upset about the parts you can't control isn't going to do a lot of good. Getting upset about what the government is or isn't doing, getting. Getting upset about where this virus originated from, not going to do any good. You know, it is what it is. That's not within your control. What can you control? You can control your behaviors, you can control things to help yourself stay safe. What is your hoped for resolution and is this realistic? And finally, let's make some possible steps to a solution. If you want to stay happy and healthy and survive this crisis, what do you need to do and what options are out there? And the options are increasing dramatically. As you know, in this particular situation, as Congress makes money available to small businesses and to people who aren't able to work, I imagine there's going to be some trickle down money to help people who are get behind on their rent payments or their mortgage payments because of inability to work for a, you know, short period of time. So there's the possibility of a lot of resources. So we need to encourage people to not assume that the worst is going to happen and to make sure that they are availing themselves and making themselves aware of all of the resources that are out there as they become available. We want to use authenticity to communicate how much we want to help people find a way to stop hurting and find a way to stop being anxious. We can help them again, look for exceptions. If they don't have any examples, then we say, okay, how have other people solved a similar problem in the past? We can look in this particular situation, we don't know much about this current virus, but we can look at how have we protected ourselves against the flu, how have we protected ourselves against Middle east respiratory syndrome or sars? We have had other epidemics in the not so distant past. What steps have we taken that would apply here? Set small achievable goals, making sure that people are focusing on, you know, what they can do in the moment. Maybe they're not going to go all day without getting anxious, but maybe they can focus on trying to not think about the problem or do something positive. However you want to look at it for an hour and then maybe do something else for an hour and take it hour by hour for a little while. If that's what they need to do, they can try using narrative therapy. Write down what's going on. This is the chapter or the season that is going on. Write it down. And then the next chapter in the book is how they see the future. When this situation resolves, what's it going to look like? What are they going to be doing? What are they going to be doing differently or the same? Who's in this current situation, who's there, what are they doing and how do they feel? And in the future, who's still there and what are they doing and how do they feel now? If we want to take a little bit a chapter out of the Acceptance and Commitment Therapy handbook, we can also look at living in the and and this is very similar to what Kobasa began proposing back in 1979 with hardiness. Living in the and means helping people accept that a lot of times there is going to be distress, but there can also be happiness at the same time. We have multiple facets to our life and while some things may be going kind of crappy, there's probably a lot that is going the way we want it to that we need to remember to focus on. I can be anxious about getting this virus and live a rich and meaningful life today. I didn't go to the gym because, you know, I'm in a high risk category. So I didn't really want to go into a public place, especially where people are breathing heavy. But so I stayed home and I worked out on my spin bike at the house. Living in the and I can be anxious about the virus and take care of my health, which is important to me. Help them identify things that are important to them that are going well. Sometimes people can't see what's going well, so it's important for them to identify, you know, what am I grateful for right now, what is going well in my life. And they can make a gratitude tree. They can make a collage, a scrapbook, or even just index cards that they put in a box in Each index card, they write down who or what it is that they are grateful for, why it's important and why it's going well. So when they start having a moment that they start feeling overwhelmed and start feeling like, you know, everything's falling apart, they can pull that out and reflect on the fact that, you know, what it actually going okay. You know, some things are, some things may still be going kind of crappy, but I do have all these things over here that are also going well and that helps buffer. It's kind of like we've talked before about running a bath. And if you want to think about the distress as being the hot water and when you focus on some of the good things, it's kind of like adding the cold water and it makes it more tepid. It's not going to be super cold, but it's not going to be so hot that it's burning you and making you miserable. Supportive interventions are necessary to help people radically accept their feelings and the situation and get into their wise mind. And that is so much easier said than done. Solution focused interventions will help them address the situation and start moving forward to break that distress cycle. Helping them identify what solutions they're willing to try. Helping them focus on what parts of the situation are actually in my control. What can I do to improve the situation for me and how am I going to do it? Instead of just talking about the possibilities, you know, then they have to move, move into actually taking those steps to improve their situation. Are there any question? Alrighty. I appreciate everybody being here with me today. On Monday we will be doing class tomorrow and that is focused on anger management skills. So gonna kind of do a bit of a 180 and so hopefully I will see all of y' all tomorrow at 12 o' clock my time and whatever time it is where you live. Everybody stay safe, wash your hands and make sure to wipe down those mobile devices multiple times a day because they get grody. 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