Dimensión Ambiental

For each of the six modes described in Chapter 5, there is a corresponding set of concrete actions or comm-unications that reflect the therapist’s use of that mode.

These responses are referred to as response modes, and they include:

For purposes of review, advocating responses are communications and actions that respond to a need for physical or interpersonal resources or raise the client’s awareness about available resources. Advocating responses may also serve to validate the client’s perception of power differentials and injustices and assist the client in taking action to overcome those injustices. Collaborat-ing responses are those that encourage and incorporate a

Box 7.1 A Mode Shift with Yoni

Y

oni is an eight-year-old Israeli boy with cerebral palsy and a severe learning disability (mental retardation). The aim of the treatment with Yoni was to get him to stand for a few minutes.

Although this was the reason for referral decided on by the staff during his IEP planning, I felt that without Yoni being highly motivated we would not get though to him. My plan with him was to work with him on standing in the Snoezelen.

The treatment would take the following pathway: Go into the Snoezelen with Yoni. Watch his behavior and see what seems to interest him on that particular day. Follow his lead, go to the equipment he seems to prefer. Mirror his behavior—if he bounces up and down I will do the same, if he makes sounds I will do the same. I decided to interpret the bouncing as his way to gain some proprioceptive input into his joints while we both enjoyed the communal interaction. In doing this I was in a situation of completely empathizing with Yoni and mirroring his behavior. I was having a conversation with him by way of our mutual body language, like both of us moving together in some kind of dance.

The natural limitations of therapy prompted a mode shift.

Time was up, and I needed to end our session. I prepared Yoni for the end by shifting from the empathizing mode into the instructing mode. First I warned him that we would soon be

ending our time together, and I encouraged him to begin our ritual of waving goodbye to the equipment. As I turned off each piece of equipment his face showed definite disappoint-ment, but he had grown accustomed to our ritual and he knew that I would stick to my limits. He also knew that the end of our ritual involved a game, which required me to make yet another shift into the encouraging mode. Yoni knew that when all the equipment had been turned off he would receive a chal-lenge. When he was younger the challenge was to touch the bubble unit. I would then turn it on for a minute before we left the room heading back for the class. Today Yoni knows that more is expected of him. He must make a sound! No sound—

no more bubbles. But if he makes a sound he gets the bubbles.

Inevitably Yoni makes the desired sounds.

In the first part of our session I was very undemanding and used the empathizing mode. In the next part of the session I was forced to utilize the instructing mode to set a limit because our therapy time was coming to an end. In the final part of the session I present Yoni with a challenge and for this I have to change attitude or shift into the encouraging mode. I think this is right. The same person can “change hats” during treatment without muddling a client.

— Michele Shapiro

Chapter 7 Navigating the Challenges: Therapeutic Responding and Interpersonal Reasoning 143

Table 7.2 Examples of Therapist Communications and Actions According to Response Mode

• Show emotional resonance or share your personal emotional reactions and thoughts about a client’s difficulty

• Strive to understand the nature and source of a client’s difficulties through gentle inquiry

• Listen and bear witness silently

• Articulate or describe a client’s affect so he or she knows you see and support it

• Admit a mistake you made and apologize for it

• Wonder to yourself if a client’s negative behavior is related to something you said or did

• Rely on your emotional reactions to clients to inform clinical reasoning

• Reveal something about yourself or your own life experience to build rapport

• Change my interpersonal style to better match that of a client

Activity Focusing

• Share your emotional reactions with a client (only if appropriate and if they match the client’s affect and thought content)

• Mirror a client’s breathing, body movements, or facial expressions

• Join a client in an activity (e.g., jumping up and down together on a trampoline)

• Perform the same activity in parallel with a client (e.g., string beads alongside a client)

• Position your body (e.g., sit, stand, or recline) alongside a client

• Use touch to convey empathy (only if appropriate)

• Provide the client with a transitional object, or small token, that he or she can remember you by

• Choose an activity to do with a client that is gratifying, comforting, or conveys an understanding of his or her thoughts or feelings

Encouraging Responses Interpersonal Focusing

• Use humor

• Encourage or coax a client

• Normalize a concern or event

• Stroke, praise, or label a client’s strengths or achievement in therapy

• Reassure the client

• Remind a client of his or her existing strengths or capacities

• Provide a client with hope for improvement

• Tell a client you are confident he or she will be able to complete a task

Advocating Responses Interpersonal Focusing

• Encourage the client to be assertive with others about his or her needs

• Validate or point out (if appropriate) an injustice or other power differential that a client is facing

• Openly discuss an injustice or power differential that exists within the treatment setting or within the treatment relationship and its implications for the client

Activity Focusing

• Provide opportunities for and encourage clients to have contact with disabled peer role models who you know will help support his or her pride and identity as a disabled person

• Encourage the client to educate him/herself about his/her entitlements and rights as a disabled individual

• Utilize your professional capacity to advocate/argue on a client’s behalf to obtain a needed resource or outcome

• Encourage a client to take action against an injustice, if appropriate

• Assist a client in taking action against an injustice by serving as a witness or becoming involved in a legal or advocacy-type activity

Collaborating Responses Interpersonal Focusing

• Gather feedback from the client before choosing or recommending any activity

• Encourage a client to make more decisions during the therapy process

• Ask questions to help a client identify life alternatives

• Share with a client how his or her behavior makes me feel

• Ask a critical client about his or her reactions to me as a therapist

Activity Focusing

• Change something about the activity, choice of activity, or environment in response to client feedback that your therapeutic approach is not helpful

• Provide a client with ample choices for occupational engagement

• Ask a client to recommend his or her own goals for therapy

Empathizing Responses Interpersonal Focusing

• Make summary statements to bear witness to the event and verify your understanding of the client’s perspective

(table continued on page 144) client’s active participation, choice, and decision-making.

Empathizing responses serve to understand, share, witness, and validate a client’s thoughts and emotions. Encouraging responses uplift, inspire, complement, and reinforce.

Instructing responses intend to teach, demonstrate, inform, and provide structure for a client. Finally, problem-solving

responses engage clients in describing, evaluating, and sometimes questioning a series of options and possibilities.

Although the number of possible responses that fall within each mode category is limitless, the responses listed in Table 7.2 are among the most commonly observed in occu-pational therapy.

Each response mode is divided into two categories:

those that typically involve verbal (or signed) responses of an interpersonal nature (interpersonal focusing) and nonverbal responses, which involve some action or activity (activity focusing). As introduced in Chapter 3, the IRM asserts that it is important to strike a balance between interpersonal focusing and activity focusing—

or the amount of time in which interpersonal issues are discussed and processed relative to the amount of time in which the therapist takes some other nonver-bal action to address an interpersonal issue. Some clients do not look for or are not able to tolerate much direct dialogue about issues within the relationship, whereas others feel more comfortable if everything pertaining to the relationship is communicated openly and verbally (Fig. 7.3).

When an interpersonal event occurs, it typically serves to intensify any underlying vulnerabilities or chal-lenging aspects of a client’s interpersonal style. This increases the need for best-fit matching of a given response mode to a client’s interpersonal characteristics. Thus, the same considerations that inform a therapist’s decision to shift modes should also guide the category of response mode or sequence of response mode categories selected.

These guidelines include consideration of:

Table 7.2 Examples of Therapist Communications and Actions According to Response Mode (continued)

• Question or address a client about his or her lack of follow-through

Activity Focusing

• Model or demonstrate for the client how to perform an occupation

• Introduce a limit or boundary nonverbally

• Choose activities that test or challenge a client’s perception of his or her performance capacity

Problem-Solving Responses Interpersonal Focusing

• Assist the client in evaluating all of the potential consequences of a choice or action

• Assist the client in listing or articulating the pros and cons of a decision

• Assist the client in generating hypotheses (i.e., potential solutions or explanations) to address an unknown or to solve a problem

• Ask questions to help a client correct illogical thinking

• Initiate a process of conflict resolution Activity Focusing

• Introduce a new technique or technology

• Ignore a client’s negativity and focus on intervention strategies

• Redirect an emotional client back to the activity or task Activity Focusing

• Downgrade an activity or select a no-fail activity to be sure the client will have an experience with success

• Choose a pleasurable, comforting, energizing, or mood-enhancing activity

• Engage in entertaining behavior or antics

• Show positive emotion, joy, and enthusiasm through body movements, facial expression, and tone/volume of voice

Instructing Responses Interpersonal Focusing

• Instruct a client on how to perform a given occupation

• Provide a client with information or advice

• Remind a client of important safety issues

• Remind the client of the likely consequences of a given choice

• Clarify a request or instruction

• Provide a rationale for your request, approach, or behavior

• Label an interpersonal event to raise or heighten the client’s awareness of it

• Provide a client with feedback

• Prepare a client for an upcoming discussion, task, or activity

• Share your professional opinion or perspective with a client

• Recommend an alternative way of interpreting the situation

FIGURE 7.3 Michele Shapiro shifts modes quickly in response to a client’s changing behavior

• The interpersonal characteristics that underlie the client’s preference for one type of response versus another

• The nature and significance of the interpersonal event to the treatment relationship

Chapter 7 Navigating the Challenges: Therapeutic Responding and Interpersonal Reasoning 145

• Overarching issues involving the client’s safety and other ethical obligations that take precedence and should dictate that the therapist choose a specific response mode (regardless of the client’s preference)

A summary of the modes that offer the best chance for a match with various client characteristics was pre-sented in Table 5.1. Although it may be helpful as a rough guide, the summary lacks the context that is otherwise present in live interactions. Thus, it is by no means com-prehensive or completely reliable under all circumstances.

More complex and challenging constellations of client characteristics make it increasingly difficult to choose the correct response mode consistently. With interpersonally challenging clients, a sequence that includes two or more modes is often what is required to respond to an event in a way that feels satisfying to the client. Conversely, when a client possesses few or no challenging interpersonal char-acteristics, the therapist has access to a wider range of potential response modes. In these circumstances, the IRM recommends that therapists focus on selecting the response mode that is most appropriate given the

interper-sonal event that has occurred. If the therapist is successful in his or her selection, one type of response typically is enough to resolve the event. A summary of response modes according to categories of interpersonal events is presented in Table 7.3. As with Table 5.1, Table 7.3 should be considered a rough guide that requires additional judg-ment that can only occur in a live interpersonal context.

In many clinical interactions, when interpersonal events occur either the therapist’s response or the challeng-ing nature of the event itself may precipitate the occurrence of one or more additional interpersonal events. When more than one interpersonal event follows the therapist’s initial response to a single interpersonal event, this process is known as an interpersonal event cascade. The example of my interaction with Vera illustrates this phenomenon.

When Vera²pushed one of the boundaries of therapy by asking me if she could live with me, her insistence on a yes or no answer forced me to make a statement designed to interrupt the boundary violations. (The first behavior that

Table 7.3 Response Modes According to Interpersonal Events

Problem-Event Advocating Collaborating Empathizing Encouraging Instructing Solving Strong

2All client names and geographic information have been changed.

•indicates that this mode may be most appropriate for the event category.

defined a boundary violation was Vera’s asking to live with me, and the second was her demand that I respond in a very specific way by saying “yes” or “no.”) Predictably, my use of the instructing mode to explain to Vera why she could not live with me was perceived as hurtful and rejecting.

Thus, my response mode, which I perceived necessary, was now considered to represent an empathic break in Vera’s mind—the second interpersonal event in the sequence. Vera confirmed that the empathic break took place when she shouted: “I thought you were someone who cared about me.” I choose to address the empathic break by empathiz-ing with Vera (e.g., “Vera, I know you took a risk in askempathiz-ing me if you could come live with me, and I can see why you feel hurt that I said no. I want you to know I still care about your happiness here”). At that point, Vera began to sob and stormed away. Thus, a third interpersonal event occurred in the form of Vera’s expression of strong emotion.

For complex clinical interactions such as this, it is recommended that the therapist draw upon more than response mode category to address the issue at hand. When a therapist employs more than one category of response mode episodically to address a single or sequence of inter-personal events, it is known as a response mode sequence.

In the situation just described, I was first using the empathizing mode when listening to Vera talk about her displeasure about living in the group home. Vera then pushed me to shift to an instructing response that consisted of an explanation of why she could not live with me. When Vera perceived my limit setting as an empathic break, I shifted promptly to provide an empathizing response in which I acknowledged that I had hurt her feelings and con-veyed that I still cared. This led Vera to sob and storm away, an expression of strong emotion. At that point I chose to continue functioning within the empathic mode.

When Vera returned, I assessed her understanding of what occurred between us, and it appeared as though she no longer wanted to discuss the situation. Responding to her need for less intensity, I suggested we go to the kitchen and prepare Vera’s favorite dessert together. Thus, I used a sequence of different response modes to address the cas-cade of various interpersonal events that occurred.

Another variable that led to the decision to use this particular sequence of responses involved the extent to which Vera was able to tolerate direct conversation about the empathic break that I made. When she returned from her emotional episode, I asked Vera for feedback regarding how she now felt about our conversation. It was clear in her nonverbal behaviors and in her reluctance to provide any feedback that she no longer wished to discuss it. For this

reason, I shifted from utilizing empathic responses that involved interpersonal focusing to an empathic response that consisted of activity focusing—baking Vera’s favorite dessert together. Because my verbal response caused Vera to become overwhelmed with emotion, I was prepared to provide a less intense empathizing response that involved engaging in an activity.

Step 5: Draw on Any Relevant

In document Plan de Gobierno Regional Apurímac Partido Político Frente Amplio (página 143-148)