Clinical Portfolio: Never Giving Up
Four years ago when I was admitted into the Marriage and Family Therapy Master’s program, I could have never imagined the knowledge I would have gained in the field. The program has shaped the way I conceptualize and investigate therapy and helped me focus on my personal aspirations. The influx of information during my time as a graduate student created a new thought process, one that is eager for insight. I spent my undergraduate career understanding the importance of diagnosing clients, however, this has since changed to a more non-pathologizing approach when working with clients. The world of hard sciences sees the world in black and white. It is either true or false, right or wrong, yes or no with no in between. The psychiatrist sees a client as having depression or not. The family therapist, instead, sees it as a rainbow, where a client could have depression, but there may be other factors involved, besides depression. During this paper, I will further examine myself as a therapist and the role I play in the therapy room when working with clients.
Philosophy of Treatment
The question of “Who am I as a therapist?” continues to go through my mind while writing this paper. This is a question that has endless answers, because as a therapist, I am always growing. I am the optimist who finds strength within the individual even in the worst situations. Strength is something that I utilize frequently in the therapy room, and I highlight strength by using compliments. I am the therapist who meets the client where they are and let the client guide the session. In the therapy room, I create an environment in which the client feels safe, accepted, comfortable, and understood. I see the client as an equal, and the client is the true expert of their life. I am the therapist that is open to continuous feedback, as I believe that is how I grow as a therapist. My personality and ability to adapt to the client is what makes me the therapist I am today. I believe individuals and families come to therapy because of their perceived idea of being stuck. This perception is indicative of the dysfunction of the current system, but goal-focused therapy can shift this perception.
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According to Solution-Focused Brief Therapy: A Hand Book of Evidence Based Practices, therapists that embrace solution-focused therapy are characterized by (a) warm and friendly demeanor, (b) naturally positive and supportive attitudes, (c) open-mindedness and flexibility in incorporating new ideas, (d) excellent listening skills, especially in listening for clients’ previous solutions embedded in problem talk, and (e) tenacity and patience (Franklin et al. 2012, p.34). The therapist I am today comes from my background and upbringing, in addition to the way I interact with people. My parents always highlighted my strengths, which benefitted, empowered, and allowed me to recognize these qualities that I could not see in myself. This ability to see the best in people has persisted with me. Whenever I encountered a problematic situation, they would use my past successes to instill self-confidence and help me see that I have the strength to accomplish any goals I set. My parents also motivated me to not dwell on the past, but focus on the present and the future. They stressed the importance of setting small and concrete goals, instead of extremely difficult one that result in a feeling of frustration and hopelessness. They continue to encourage me to set smaller goals that contribute to my larger goal. These core principles make up the therapist, and more important, the person, I am today.
During my time in the program and working in the field, I have challenged myself to explore the models of family therapy to better understand who I am as a therapist. The ideas that are paramount in solution-focused therapy are embedded in my worldview and how I function in society. I am naturally strength-based and drawn to models that highlight clients’ strengths. I naturally believe that clients want to change and possess the tools to change. I believe the overall goal of therapy is to validate and build up clients in a way that elicits positive change. Solution-focused therapy is grounded in post-modern ideas due to the explorations of meanings. This model is optimistic, future-oriented, and builds off strengths and resources. I have always been an optimistic and strength-based person. The core principle of the post-modernism framework is that our reality is subjective rather than objective, because no objective reality applies to every individual. Furthermore, the post-modernist would say there is no foundation of what is knowledge or what is not. This idea of knowing is subjective to the individual. Our context is created through interactions, knowledge, and meanings. All three of which are not stable but ever-changing. Post-modernism also takes the stance that client and therapist have equally valid perspectives and that each client is the expert of their lives. Instead of using facts, therapists are seen as having perspectives, and therefore, the therapist is not taking the expert role. When working with clients, I gravitate to exploring exceptions and the differences in those times. As Bateson discussed, “there are differences between differences. Every effective difference denotes a demarcation, a line of classification, and all classification is hierarchic. In other words, differences are themselves to be differentiated and classified” (Bateson, 2000, p. 463). The noticing of differences within patterns can create ultimately other differences within the individual and/or system. Steve de Shazer, Insoo Kim Berg, and Bill O’Hanlon created the fundamental ideas of solution-focused therapy such as the idea of shifting from problem talk to solution talk. A solution-focused therapist acts as a consultant to help clients recognize their goals, resources, strengths, and what works for them, and then helps them do more of what works. The model believes that in order to achieve change, the client must focus on solutions and their preferred future, rather than on the problem and what is not going well in their life. People have the strength and resources to change, and change is achieved by using questions that are designed to define goals, construct solutions that may be existing options in the client’s life, and finding exceptions and facilitating the re-experiencing of those exceptions. In summation, the client’s abilities, strengths, resources, and solutions are most important in helping to bring about change.
When using exceptions questions, complimenting, and highlighting strengths, the client is able to notice the positive attributes they possess. Compliments are seen as reinforcing clients’ positive behaviors. Solution-focused therapy emphasizes the importance of clear, specific, and concrete goals which is helpful in accomplishing them and realizing when things have improved. Goals are discussed and explored during sessions. When I am doing therapy, I have noticed that many goals come up when the client and I are having natural conversation. Scaling and miracle questions help guide the session to further explore those differences. For example, when a client responds that they are at an eight, the therapist can dig deeper by asking the client what would need to happen to get to a nine. As Berg and Miller (1992) explained, the scaling question invites the client to discuss the individual perspective, client’s view of others, and the client’s impression of how others view them. The miracle question examines the client’s world if they reported the problem as no longer present and following this question, I like to further explore ways that the answer to the question could potentially become a reality. Coping questions are asked to have a conversation about the resources the client already has within and how those can be utilized. Steve de Shazer (1988) discussed tasks, such as homework, when presented very casually as a choice using this idea of customer, complainant, and visitor have a higher chance of completion and I have to agree with the way it is presented depends on the likely hood of it being done.
Diversity and Culture
Diversity is what sets people apart from others and sculpts us into unique individuals; however, diversity is intriguing, while challenging at the same time. It pushes a therapist to dig deeper and form new, distinct conclusions. Thus, marriage and family therapy is more than being able to remedy a situation, it is having a diverse understanding of all aspects of a case and its background. My ability to comprehend that there is an endless amount of diversified conditions waiting to be alleviated invigorates me. I believe culture and diversity is something we should always consider as a part of the client’s context. Every culture has different norms and traditions, making each cultural reality different from the other. Solution-focused therapy considers that there is no universal culture or universal way as each individual comes from a different contextual background. Due to the one-down stance taken by the SFBT therapist, there is room for respect and attention to each client’s unique life experience and culture. In my opinion, keeping an open mind and non-assuming stance is imperative to a successful therapeutic relationship. A therapist must possess skills that allow one to join and work with clients of various backgrounds to help them develop solutions that fit their values and worldview. As mentioned before, the solution-focused approach is client-centered and the therapist takes a curious “not-knowing” stance. Therefore, cultural diversity is honored when using this model as the therapist is open to learning about the client. The solution-focused therapist does not make assumptions about the client’s culture, but rather asks questions and remains inquisitive.
Ethics and Professionalism
Ethics and professionalism are two key components of being a good therapist. The American Association for Marriage and Family Therapy Code of Ethics (2018) stated “marriage and family therapists are defined by an enduring dedication to professional and ethical excellence, as well as the commitment to service, advocacy, and public participation.” I am always seeking supervision and support to uphold the professional and ethical excellence that is expected. Even when I become licensed, I will continue to seek support as I know I am not alone when dealing with an ethical dilemma or crisis. When working with my clients, I am transparent, present, curious, outgoing, and non-judgmental, all of which contribute to rapport building with my clients and being my best self as a therapist. I am always going over confidentiality with all clients no matter how many therapists they have already seen. For example, I had a client say to me that I can skip over the introduction, however, I spoke with them about the importance regardless. When working at the Brief Therapy Institute, I discuss with my clients the role and purpose of video-taping. Whether in the therapy room or running errands, I am always presenting myself as my most professional self. I check my biases and assumptions to remain non-judgmental throughout the session. I look to participate in different training courses involving the Health Insurance Portability and Accountability Act (HIPAA), ethics, and professionalism to continue growing as a therapist, an endless endeavor. Related feedback is crucial for professional growth and without the honest feedback I have received from professors, I do not believe I would be the therapist I am today.
With the client discussed below, an ethical dilemma I faced was the client interacting with me as if I was a close friend. Many would say that the client feels comfortable speaking to me, however, I believed it was challenging the therapist-client relationship. During session eight with the client, I discussed my role as the therapist and the role of therapy. Although this was the eighth session, the client had 54 prior sessions with other therapists at the Brief Therapy Institute. I believed I needed to discuss the role of therapy to further explore if the client was benefitting or becoming dependent. As the American Association for Marriage and Family Therapy Code of Ethics (2018) stated, “Marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship.” The client reported that she enjoyed coming to therapy to process what is going on with the relationships around her and has noticed a shift within herself and how she interacts with others. I asked the client when she will no longer need therapy, to which she was unsure. Furthermore, I explored the possibility of skipping a week and asking her to observe what they did in place of therapy. I did not pressure the client, but I wanted her to know she had the option in case she felt she had to come. I continue to check in with this client about the role of therapy and have since sought out supervision about the case.
Case Study
At the Brief Therapy Institute, I have been working with an individual client for approximately 17 sessions since March 2018 with Dr. Heller, Dr. Wilson, and Dr. Burnett. Amy is a 45 year-old Caucasian female. Amy is a United States Navy veteran and currently unemployed due to disability. Amy has had many traumas throughout her life, such as being in the foster care system. She currently lives with her partner and has her children every other weekend. Amy has a 12 year-old son and a 14 year-old daughter. She reports coming for therapy due to an on-going custody battle, resulting in a challenging relationship with her children and little communication with her ex-husband. Numerous abuse allegations made by her children and her ex-husband have caused her to be very careful while interacting with her ex-husband and children.
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In our first session, Amy had no idea she was getting a new therapist after unexpected circumstances with the prior therapist. I was able to meet Amy exactly where she left off and we had a session that looked like it was not our first. The solution-focused model encourages the therapist to take a “not knowing” stance, allowing the clients to be “experts,” rather than the therapist telling the clients what is “really” wrong and how to fix it. I am naturally curious and believe that every person is unique in their own way. I like the idea of seeing clients as the experts of their lives, and not taking the role of “expert” in therapy. For this 1st session I was a part of a maintained theme across the sessions which was this idea of being present. I used the Amy’s language to further explore this theme. In being present the Amy is able to listen more rather than being on the defense. I utilized questions such as how is this a problem for you? Too further explore how being defensive has not worked for her, and other attempted solutions she’s tried prior. Amy has reported having a tendency to let her mind race on a topic which consumes her; furthermore, this idea about being present is something new for her. Amy tends to discuss her history and past rather than ways to shift her future. Amy would be seen as the complainant in beginning sessions due to her not wanting to do anything besides wanting someone or something else to change. In this case, she is wanting her ex-husband to change and she believes that this custody battle has gotten to this point because of him. Changes in perception lead to changes in behavior and this can be achieved through language. As the therapist and client shift to solution-talk, they come to believe in the truth and reality of what they are discussing. Shifts from problem focused talk such as how long have you been defensive to solution focused talk such as what would your life be like if you weren’t defensive, change the conversation during the sessions.
During the 2nd session, together we explored exceptions which highlighted that she has small moments with the children. Prior to highlighting these small moments the client discussed having no moments with the children. I was able to highlight this exception when the client discussed giving her daughter a necklace for her birthday and the daughter putting the necklace on. I highlighted what was different during that time as no fighting was present when she put the necklace on. During conversation, I encouraged her to explore more what works for her and then doing more of that; furthermore, this is done by exploring with the Amy the times when the problem doesn’t happen and then inviting the Amy to re-experience those times. Questions such as, what was that like for you to be present and listen to your daughter and it sounds like you did something different by just listening when you gave her the necklace, demonstrate application of the exception in more routine aspects of life. I explored with Amy the goal of therapy, and Amy reported that she would like to explore how she is managing her relationship with her children. During the thired session, the Amy shifts from the complainant to the customer as Amy became active with regards to talking about the present and wanting to do something about her situation rather than discussing her ex-husband and the past. I started this session with the question what changes have you noticed that have happened since your last session? Amy responded that she noticed she is remaining calm and present in situations that would’ve made her defensive in the past. During fourth session, Amy responded that she is noticing she is just being more present and not letting herself become overwhelmed by things she can’t control. In both sessions, I highlighted and complimented the shift the client made. I asked Amy the question. I wonder what would happen if you stopped telling them what a good mom you are and how they would discover that just from you being present? Following this, there was a therapeutic silence which has always been a challenge for me, but I am learning to accept the silence. Amy responded with how much she time and energy she puts in to proving to others she is a good mom. I wonder what if Amy let the kids discover similar to in therapy how the therapist doesn’t tell her what it is but lets her discover what it is.
During the fifth, Amy came to therapy a little bit more down than usually. Amy reported that she was frustrated with her children and they don’t realize how much she is trying. I shifted the conversation back to Amy by asking what gives you hope that this problem can be solved? Amy discussed the small interactions she has with her children provide her hope that their relationship one day can be fixed. Following this, I asked Amy the miracle question for her to further explore what it would look like if the relationship with her children shifted. I like the miracle question because it assumes that the problem will not always be a problem and explores when, not if, resolution takes place. I asked Amy, let’s say, while you are asleep, a miracle happens and the problem that brought you to therapy is no longer present, but since you are sleeping you don’t know that the miracle happened until the morning; furthermore, when you wake up in the morning, what will be different that will tell you that the miracle has taken place? (Gladding, 2002). Amy discussed that she would know a miracle took place if her children interacted with her differently. I dug deeper with Amy by asking what does interacting with her differently look like? Amy responded that her children would want to do things with her willingly. I asked, what would need to happen to do this? Amy discussed that she needs to let them come to her. Amy discussed the relationship with her children as a tug war match both are not letting go; furthermore, I encouraged Amy to let go of the rope just a little to see if that opened the door for them to willingly be with her.
The on- going goal of how Amy is managing her relationship with her children continues to be explored throughout sessions 6 and 7. Each week Amy comes in with many different stories with the same fundamental problem. I respectfully and empathically listen to the client and have an open conversation with the client. With these stories, I notice myself trying to dig deeper. The client opened up about her need to be involved in her children’s life. This has been a continuous conversation throughout therapy as to what does being involved in her children’s life look like? And how will she know when she is involved or not? Amy discussed that the weekend prior her daughter asked her to go shopping with her. I highlighted how that was a shift since the prior sessions. Following this, I asked Amy a scaling question for her to see where she thinks her relationship is with her children on a continuum. I asked, on a scale of 0 to 10, with 0 being you have no involvement with your children and 10 being you are very involved with your children, where do you think your relationship with your children is? Amy discussed that she felt her relationship was at a 5. I asked, what would it take for you to increase from a 5 to a 5.5? Amy discussed she believes the score would increase if she was not so defensive with the children as she still gets defensive at times when the children discuss things that aren’t true. This was a big shift for Amy because she had put the change needing to happen on herself versus others. Prior to ending the session, I highlighted all the changes the client has been since I starting working with her, and encouraged her to notice the times she thinks the scale is at a 5.5 and what is different those times.
As I continue to work with this client the changes she has made are very clear This theme of being present has no only effected the relationship with her children but many other relationships she is involved it. As Linn and Spiegal (1969) discussed, how a small amount of change can increase optimism and confidence which creates a ripple effect of change throughout. The ripple effect in this case is very clear. In my most recent session with this client around two weeks ago I sat there and listening to a client who at one point was able to self-reflect. Amy discussed that her new normal 6 months ago was defending herself and now her new normal is being fully present. I complimented Amy on her ability to reflect on her behavior, feelings, and relationships. Amy discussed how with being less defensive and more present she’s noticed how she is sleeping better and just overall feeling better. We discussed how much energy is used when one is being defensive, and discussed where are other places she can put all this extra energy. Amy discussed that she has never gave up on the relationship with her children; however, I highlighted how Amy never gave up on herself and with never giving up on herself she was able to build a relationship with her children that hers and no one else’s.
This case has taught me a lot about myself as a therapist and what I need to work on clinically. I want to continue expanding my knowledge on other family therapy models as I want to be as well versed as I can possibly be. Being open to trying different things in the therapy room is beneficial in exploring models and something I need to do more of. I preach to my clients trying something different and I should follow by example. With this case, I was challenged because Amy would go on many tangents; furthermore, I need to work on being more active in the therapy room with regards to shifting the conversation. Also, taking a break during sessions is something I have been doing more in recent sessions as it is something I don’t always do. I believe a break during session allows me to collect my thoughts and allows the client to process everything that was discussed in the first portion of the session. I will continue to grow as a therapist and expand on the feedback I am given when in the field in order to be the best clinician I can be.
References
- American Association for Marriage and Family Therapist. Code of Ethics. Retrieved from https://www.aamft.org.
- Berg, I. K., & Miller, S. D. (1992). Working with the problem drinker: A solution-focused approach. New York, NY, US: W W Norton & Co.
- Bateson, G. (1972). Chandler publications for health sciences. Steps to an ecology of mind: Collected essays in anthropology, psychiatry, evolution, and epistemology.
- Franklin, C., Trepper, T. S., Gingerich, W. J., & McCollum, E. E. (2012). Solution-focused brief therapy: A handbook of evidence-based practice. New York: Oxford University Press.
- Gladding, S. T. (2002). Family therapy: History, theory, and practice. Upper Saddle River, NJ: Merrill-Prentice Hall.
- Spiegel, H., & Linn, L. (1969). The “Ripple Effect” Following Adjunct Hypnosis in Analytic Psychotherapy. American Journal of Psychiatry, 126(1), 53-58. doi:10.1176/ajp.126.1.53
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