Socratic Method of Teaching & Learning Psychotherapy 12_01_2023 (3)

1. ADVANCED METHODS IN COUNSELING AND PSYCHOTHERAPY The Philosophy and Practice of Clinical Outpatient Therapy Demetrios Peratsakis, MSEd, SDSAS, LPC, ACS, Certified Clinical Trauma Professional Executive Director, Western Tidewater Community Services Board

2. DISCLAIMER The purpose of training is to help improve one’s practice of therapy through a deeper understanding of methods. This material is intended to augment, not replace, the instruction and practice expectations of one’s home agency or Community Services Board. As such, the ideas presented herein are simply those that assist me in my work and in my understanding of human motivation and pathology. ____________________ . ____________________

3. A Word of Gratitude for My Clinical Supervisor I trained with Dr. Robert (Bob) Sherman, who guided my work from 1980 until his retirement and relocation from New York City, in 1992. Bob, was an AAMFT Clinical Supervisor, author, co-founder of Adlerian Family Therapy, a long-time Fellow at the North American Society of Adlerian Psychology, and Chair of the Department of Marriage and Family Therapy (MFT) Graduate Programs at Queens College which he founded, where I degreed in MFT, Guidance, and School Administration, and where I served as faculty in 1986 and 1987. During this time I joined small group instruction at the Adler Institute of NYC with Kurt Adler (1980), Bernard H. Shulman (1980), Harold Mosak (1980,1981) and Steven Zuckerman (1982, 1983), learned hypnogogic induction from Martin Astor (1980), and attended live-practice seminars with Maurizio Andolfi (1981), Adia Shumsky (1982), Carlos Sluski (1983), Murray Bowen (1984), James Framo (1985), Bunny Duhl (1986), Monica McGoldrick (1987), Carl Whitaker (1988), Jay Haley (1989), Salvador Minuchin (1990, 1991), Salvador and Patricia Minuchin (1991) and Peggy Papp (1992). In 1990, I joined Dr. Richard Belson, Director of the (Strategic) Family Therapy Institute of Long Island, in a 2-year, live-supervision practicum treating chronic, highly intractable problems. Belson, an intimate collaborator with Jay Haley and Cloe Madanes at the Family Therapy Institute of Washington, D.C. (1980 to 1990), was on faculty at the Adelphi School of Social Work and serving as a senior Fellow on the editorial board of the Journal of Strategic and Systemic Therapies (1981 to 1993). I am indebted to these remarkable clinicians and the indelible mark they have left on our field. I am especially grateful to Bob, for his training, encouragement, and love. -Demetrios Peratsakis, MSEd, SDSAS, LPC, ACS, CCTP, Executive Director, Western Tidewater Community Services Board

4. Learning and Teaching Therapy Training in Modeling and Teaching the Practice of Therapy

5. Orientation to Practice There are literally hundreds of models of therapy, each with its own perspective on human behavior. It is important then to first clarify the assumptions under which these notes are predicated: • Our interpretations drive our feelings and actions. As social beings, these express in our relationship systems and effect our desire to trust and to be intimate. They also drive our identify and sense of worth and are employed to affirm intimacy, fealty, and social bonds. Given the critical nature of social belonging, a fundamental priority to personal thriving and to societal evolution, betrayal, in its varied forms and perturbations, is the most traumatic and insidious psychological injury. • Psychological problems originate from unresolved interpersonal conflict and trauma. These emerge or are triggered by significant life events, such as loss, enduring hardship, abuse or prolonged isolation. The ensuing pain results in depression (sorrow) and anxiety (fearfulness) fueled by overlapping feelings of Guilt, Anger and Shame (GASh). The strategies we employ to remedy and avoid pain, may help us cope, but they may also evolve into lifelong defenses that grow progressively antisocial with overuse. This, in essence, is the origin of psychopathology. • The goal of therapy is to aide adjustment and adaptation to the changes of life, as well as to provide support and solace to the need to heal trauma, reconcile conflict or remedy injustice. • The therapy session is the primary venue for the practice of new ways of thinking, feeling and behaving, as well as a medium through which clients, as well as counselors, can experience intimacy and acceptance. As a serious agent of change, the therapist actions are never quite neutral and should be viewed as either therapeutic or counter-therapeutic. Therein, lies the impetuous for additional education and training and the teaching of methods and technique. • Supervision is a transformational process, that includes the Supervisor, Counselor and Client. The resonance (isomorphism) within these relationships permits the opportunity for self-reflection and self-discovery (metamorphosis). The Socratic Team Method for Clinical Case Supervision encourages mentorship, collaboration and learning for growth.

6. Training in Counseling & Psychotherapy Notes on the Training Slides: This PowerPoint provides a brief outline of the Socratic Team Case Supervision Model, a powerful framework for counselor training and continuous skill refinement. The model is particularly helpful across all staffing levels, pulling small groups of counselors and case managers together to review casework and improve client care. By its design, the model provides a structured and dynamic format that fosters creativity, teamwork and progressive skill development in theory, methods, and practice. While training events can be helpful, its much more beneficial to have continuous skill development built into the very design of the program. This is especially true if the model promotes critical thinking and shapes the manager as a clinical resource. Several programs, such as P-ACT, ACT, FEP, SOR, MST, and FFT, already employ a similar team discussion and group supervision format. Adding evidenced based methods as part of their meetings greatly enhances their existing team structure. Supplemental Materials: Staff knowledgeable in the basics of assessment, case conceptualization, and the development of a strong Therapeutic Alliance benefit from more advanced skill development. Several subjects, key to a sound clinical footing, have been included in the slide deck under Supplemental Materials: Set B: Residents, Licensed Clinicians, and Seasoned Practitioners • Prescribing Directives, Disengaging & Redirecting Power Plays • Learning to Treat & Heal Depression • Symptom Origination, Development, and Expression • Safe-guarding Tendencies and the Psychopathology of Overreliance on Avoidance Strategies Set A: All Counselors & Case Managers • Ruling Out Neurobiomedical Issues • Understanding Psychological Problems • Triangles & Triangulation • Challenging the Symptom and the Presenting Problem

7. The Socratic Team Case Supervision Model© A Model for Small Group Clinical Supervision and Continuous Skill Development - Demetrios Peratsakis, LPC, ACS © 2016

8. The Socratic Team Case Supervision Model© strengthens skill-refinement across the three (3) inter-connected parts of the counseling process. 2. Treatment Planning Strategizing the Course of Treatment Developing an overall approach to treatment, deterring goals, and formulating the strategies and methods for problem resolution and work toward achieving desired improvements and growth. These areas compliment one another and should be in continual refinement across the life of the counseling episode. 3. Intervention Change Tactics & Methods Getting from point A to point B and implementing and refining the problem-resolution strategies and tactics for change, goal achievement, and growth. This includes selecting the most appropriate interventions, from the hundreds of techniques available and ensuring that evidenced based principles and tenets drive their selection and use. 1. Assessment Problem Analysis & Case Conceptualization Understanding the elements of the case, the reason for treatment, the client system and the particulars of the problem and why it emerged now. It includes an analysis of the life-stage, issues associated with major life tasks, strength and resiliency factors, and an overall appreciation of the source of the pain, what needs to change or be resolved, and who needs to participate or help and how? - Demetrios Peratsakis, LPC, ACS © 2016

9. Benefits of the Socratic Team Supervision Model The format, small groups of counselors and case managers brainstorming practice objectives for the treatment of complex syndromes and conditions, fosters personal and professional development. Skill development occurs in • Complex Problem Solving • Critical Thinking • Reasoning • Creativity and Innovation, and • Teamwork These build Self-confidence and promote interdepartmental cooperation. As each counselor acquires greater mastery in leading and teaching clinical practice, complementary skills are refined and become second nature: • Effective Communication, Self-assurance, and Assuming Leadership Responsibilities • Collaboration with Co-Workers • Thinking Outside the Box and Adapting New Strategies • Improvement in Organization and Time Management Skills • Development of a Stronger Work Ethic • Deepening of One’s Understanding of Human Problems and Client Care, and • An Increase in One’s Knowledge and Expertise in the Field.

10. The Socratic Team Case Supervision Model© 3 Main Ingredients A Model for Small Group Clinical Supervision and Continuous Skill Development • Small group supervision & practicum experience • 8 - 12 members (ie. QMHPs, CMs, CSACs, LEs, Licensed staff) • 90 min – 2 hours; coffee and food is encouraged  • Emphasis on brainstorming & critical reasoning (Socratic Method) • Led by any seasoned clinician who acts as the Facilitator • Apprenticeship model: format develops leadership and clinical supervision skills and fosters “future” facilitators, who then may lead their own “teams” 1 Socrates Groups or “Teams” 2 Genograms • Genograms provide a simple, yet highly sophisticated assessment tool; including key nodal events and trends, relationship dynamics, core belief mythologies and value systems. • Genogram presentations serve as a focal point for brainstorming, strategy planning, and examining alternative ways to intervene and influence change • Members learn from each other’s casework and can partner for co-therapy, peer supervision, and mutual support. Group supervision paves the way for Socratic Circles and advanced practices, including live supervision and Greek Chorus • Genograms expose possible traps, triggers, and vulnerabilities for the clinician and the clinical supervisor (Isomorphism) Role Play 3 • Experienced clinicians use Role Play to model technique and coach members on the mechanics or How To’s of practice • Role Play promotes confidence and allows group members try out, rehearse, and refine new techniques as well as to innovate and explore alternative ways of interacting, including “What Ifs?”, “Do Overs”, and “Let’s Try This…” • Role Play helps members experience the client’s perspective and can help participants work through unresolved issues • Role Play enables members to assume a more active, directive stance which is critical for encouraging leadership - Demetrios Peratsakis, LPC, ACS © 2016

11. # 1 Socrates Team (Group) Case Supervision 1 Team Supervision is a small group “practicum” experience that brainstorms treatment options. Team Members brainstorm and problem-solve clinical case solutions. This generates new perspectives for the Presenter, promotes critical thinking, and encourages group learning and peer cohesion. Casework serves as impetus for clinical discussion, instruction on special topics, modeling, coaching, and role-plays. Members are restricted from advising one another or the Presenter. Instead, Members are challenged as to how they would handle the case, or some specific portion or element of it, real or imagined. The facilitator may go round-robin with Socratic-style questions such “What would make this as: “You’ve just taken over this case and they’ve arrived for their next appointment. Tell us what you will do and why? And then what? And then?”. “If you had 3 sessions left, describe what you would do, session by session”. “If you could get anyone to participate in session who would that be? Why?”. Case collaboration promotes co-therapy, team-therapy options, in-session consultation, and peer supervision. Sharing common ups and downs builds confidence, staff morale, and interdepartmental teamwork “Why not try…?” “What do you think about this?” “What if…?”

12. Benefits of the Team (Group) Case Supervision 1 • More economical use of time, costs and expertise. • Skill improvement through vicarious learning, as supervisees observe peers conceptualizing and intervening with clients. • Group supervision enables supervisees to be exposed to a broader range of clients and syndromes than any one person’s caseload • The normalization of supervisees’ experiences • Supervisee feedback of greater quantity, quality and diversity; other supervisees can offer perspectives that are broader and more diverse than a single supervisor • Quality increases as novice supervisees are likely to employ language that is more readily understood by other novices • The group format enriches the ways a supervisor is able to observe a supervisee • The opportunity for supervisees to learn supervision skills and the manner in which supervisors approach providing guidance

13. Sample Socratic Questions 1 “Client” = individual, couple or family About Interventions • How does the client respond to your directives? • What would you try if the client was open to it? • What have you tried elsewhere that might work here? • What might you try even if you were unsure of the client's reaction? How might you obtain permission? • The client’s attendance has been/becomes spotty. What can you do to address it? What if it continued? • You discover the client won’t share a secret. How might you handle it? What if it risks harm? • Explain how you might introduce a particularly off-putting suggestion or very tricky intervention? • Who needs to get aligned with whom? How? • How might you disengage these powerplays? • How does ___ affect ___? • How does ___ tie in with what we learned before? 5. General Challenge Questions • What is another way to look at it? • How would another therapist handle this? • Would you explain why it is necessary or beneficial, and who benefits? Why is ____ best? • What are the strengths and weaknesses of ____? • How are _____ and _____ similar? • Can you rephrase that, please? • Please explain why/how ________ ? • What would happen if ________ ? • What could you have done different? • What would you try again, with another case? • How has therapy been succeeding? Failing? • If you were supervising someone else’s handling of this case, what would you have them do and why? 1. About Assessment • What/who has brought this client to therapy? • What are some of the main stressors at this time? • Why do you think the problem emerged now and not 6 months ago? What has changed? • Is this a psychological or neurbiomedical problem? What makes you say so? What about___? • Who actively participates in the problem? • Who else does the problem effect? How so? • What stage of the life-cycle is the client in? What are the normative processes & tasks involved? • What is likeable about the client? Not likeable? • How is anger handled? Intimacy? • Why this symptom? Why not some other symptom? 2. About Treatment Planning & Strategy • What’s best, individual, couple or family therapy? • What model or approach would work well here? • If the Presenting Problem wasn’t the problem, what –or who, do you imagine might be? How so? • Prior history of treatment? Successes? Failures? • Who has the power to bring this client back? • Who should attend session and why? • After joining, what’s the first thing you would try? And then what? And then? What next? • How many sessions will the PP take to remedy? • What should be the therapist’s main concern? • How can the life tasks be better adapted to? General Challenge Questions (continued) • Why do you think I/she asked that question? • What does ___ mean? • How does ___ apply to everyday life? • What do we already know about this? • How does this relate to what we have been talking about? What makes if different? • How could you verify/ disapprove that? • Can you give me an example? • Are you saying ______ or ______ ? • Do you agree or disagree with _______? • Why is that happening? • Show me how_____ ? • What do you think causes _______ ? • Why is __________ happening? • What alternative ways of looking at this are there? • Who benefits from this? • What are the strengths and weaknesses of ______? • How are _____ and _____ similar? Different? • How could you look another way at this? • What should we do next? And then? • Name some possible unintended the consequences? • How does ______ fit with what we learned before? • Why is _______ important? • What does the symptom do for the client? • What other information do we need? • What’s your reasoning for that conclusion? • How might therapy fail? What could you do/not do to help ensure it doesn’t? What else? • If we flipped a switch and everything was as it should be, what would it look like? • What does this teach you about yourself?

14. # 2 The Genogram 2 Genograms are a required for case presentation, assessment and case conceptualization Genograms provide a common assessment tool for case studies and supervision Members learn from each other’s casework, including assessment, treatment planning, methods of intervention and special topic areas, such as depression, paraphilia or work with couples. Genograms place the client(s) in a relational context and promotes thinking in systemic terms Genograms take the focus off the Presenter and makes the supervision process collaborative Genograms point to client foundation beliefs about roles, rules, gender, loyalties, myths, mistaken beliefs, familial trends and characteristics

15. 2 Benefits of Using Genograms A genogram is a family tree that emphasizes the emotional connection between its members and the nodal events, milestones and attributes that hallmark its history.It is a powerful tool for assessment, and intervention, that benefits the therapist as well as the client system. It places focus on the relationship system and the core beliefs structures that each member carries into the outside world. In addition • It reveals the medical, behavioral health, educational, occupational, and social history of its members • It reveals core assumptions and beliefs about race, gender, religion, roles, and responsibilities • It reveals family dynamics and helps the therapist make better assessments • It documents key dates and illuminates the individual and familial landmarks, including rites of passage, graduations, marriages, deaths, births, birth order, and other ceremonies or social events and that help define those experiences • It reveals the etiology of mistaken beliefs, attitudes and fictional ideals and intergenerational legacies, loyalties, and myths • It speaks to membership affiliations of who is in and out, close and distance and includes markers for intimacy, estrangement, conflict, and emotional cut-off • It speaks to issues of power and authority and provides insight as to how members interpret and express love, anger, and joy • It provides information as to intergenerational transmission including of key biopsychosocial issues such as trauma, depression, and anxiety, and points to ways that pain is expressed including gambling, addiction, paraphilia, neurosis and psychosis. Genograms may also be used directly with clients. It makes the therapeutic process more collaborative and helps remove blame and shame from the client’s experience of their family and the development of their problem.

16. Genogram Presentation Format White Board or Easel Pad 2 1. Presenting Problem & Nodal Events • Case Outline: the Presenting Problem, including nodal events surrounding its recent onset, who participates and how (denotes purpose of problem). The sequence of behaviors surrounding the presenting problem (who does what when?) denotes who participates in maintaining the problem or symptom. b) Treatment Overview: including previous therapy experiences and their outcomes, frequency and number of sessions to date, attendance pattern, regular participants and members refusing to attend or excluded. c) Challenges and Quagmires: “sticky” places and “triggers”. Known and possible pitfalls and areas of risk. Note: The more detailed the information, both factual and anecdotal, the better. It may be collected from several sources including the referring agent, the client (s), the assessment, session work, neighbors, family members and friends. A common practice is to return to a particular genogram to add information, as well as to mark and gauge treatment progress. 2. Family Constellation: Display family membership and nodal events for at least three generations • the client’s name, age, gender , occupation, spouse/partner, children, parents and siblings • the wider family such as grandparents, uncles, aunties, and their pairings and children (include names, birth dates, ages, gender, occupation , highest level of education, dates of marriage, divorce, death, etc..) • how persons are related and the relationship between family members (adoptions, marriages, sources of stress/support, alliances/collusions, etc..) • clinical and health issues such as child/partner abuse, drug and alcohol dependency, anxiety, depression, heart conditions, cancers, diabetes, etc... • ethnic and cultural history of the family • socioeconomic status of the family • major nodal events and recent trigger issues, such as pregnancies, illnesses, relocations, or separations 3. Family Atmosphere: Track and Interpret family beliefs and relationship patterns, conflicts, etc... • post the client’s symptoms/concerns and trace similar patterns across member relationships • look at roles and rules that may have bearing on the presenting problem (s); post myths, legends and value statements • look at life-cycle, nodal events and triggers for timing surrounding the presenting problem(s) • demarcate, by dotted inclusion lines, members who participates/in the presenting problem • client(s) and therapist (s) share observations and interpretations from the genogram

17. Common Genogram Symbols & Markers 2

18. 2 Genograms Reveal Relationship Structures & Emotional Boundaries Boundary Mapping Defining the Emotional Reactivity Between Individuals and Systems Sample Genogram Example: parents disengaged from one another; mother enmeshed with son M F ...........S Mapping of boundaries, hierarchies and subsystems was developed as a short-hand method of relationship description by the Structural school of family therapy.  mapped as Boundaries represent the emotional integration of the relationship between individuals and subsystems. When overly reactive or co-dependent (enmeshed) they foster difficulties with individuation, a primary process of independence, maturation and adulting. When overly detached (diffuse) emotional responsiveness is lacking and renders the members toward isolation and feeling inadequately supported. These extremes, often intergenerational social responsiveness styles, are exacerbated at times of distress or due to prolonged trauma, conflict and periods of despair.

19. # 3 Role PlayLearning to Teach (Modeling) and Practice Tactics and Techniques (Behavior Rehearsal) 3 Members refine their clinical practice through Role-play and Re-enactment Modeling (Teaching/Demonstration) of technique by more experienced counselors provides “learning by observing” Coaching by facilitator provides fine-tuning of verbal and behavioral interventions Role-play provides members opportunities to try out, smooth and rehearse new techniques (behavior rehearsal and refinement). “Do-overs” and “Let’s try this or in this way” fosters experimentation, creativity, and nimbleness. As confidence grows, the group may elect to participate in Co-therapy, Team therapy and Live Supervision As confidence grows, Team members take turns facilitating the group and later establish their own Teams

20. 3 Benefits of Modeling & Role Play Modeling (teaching) technique & Role-Playing (behavior rehearsal) provide more effective method of instruction and skill refinement  Role Play  Modeling “What I hear, I forget. What I see, I remember. What I do, I understand.”  -Xunzi (340 - 245 BC)

21. 3 Role Play is a Superior Medium for Skill Aquisition ”Students are directly active during the role play, so it is more effective in “embedding concepts” into their long-term memory. The excitement of the role play, the interaction and stimulation to visual, auditory and kinesthetic styles of learning helps a broad range of learners” - Yasmeen Rafaq

22. Getting the New Team Started 3 Once a new Team or Group has been instructed on the “rules”, format, and how to construct and craft a Genogram, its best to get them mobilized and out of their usual “comfort zone”, preferably by asking for volunteers and having them walk through a demonstration and role-play. “Empty Chair” and “Sculpting” are two, excellent techniques for energizing the new Socratic Team and helping them to experience the power of Modeling and Role-Play. These techniques have the added benefit that they promote team spirit, group cohesion and team-work. • Members become energized and interactive; the process communicates that therapy can be playful and fun, a learning, instructive experience and an opportunity to try something different, to be imaginative and think and behave in a different way. • Members learn to assume a position of authority gaining confidence over leading session and how to command or direct work • Members learn to think and work in relational terms, to see human interaction and conditions in temporal and spatial terms • Members learn to think and work in the here-and-now, to adapt, to be innovative, nimble and responsive in fostering change • Members learn how to make covert processes overt and to simplify complex operations into manageable steps Sculpting Empty Chair and Sculpting are powerful each, each with several variations. They attune focus and allow for immediate modulation of intensity and force.

23. 3 Teaching Triads: Training for Small Group Skill Instruction Structuring the New Team’s Learning & Practice Experience While working through an actual Case Presentation is the best method for acclimating the New Team to the Socratic Method, Modeling and Role Play modify each Member’s experience of supervision and clinical the clinical skill development process. Ask for 3 volunteers assigning one to play the role of the the client, one the therapist, and one the supervisor (“coach”). Demonstrate a technique, then ask the “coach” to help instruct the “therapist” on how to introduce it to the “client”. Once this has been trialed, break the remainder of the Team into “Teaching Triads” and have then walk through the same technique, alternating roles. Rotating Roles (Client, Therapist, Coach) for the Practice and Rehearsal of Technique The Lead Clinical Trainer/Facilitator models the tactic or technique and then circulates among the Triads, each led by a “coach” working with a “client”-”therapist" pairing. As each member assumes one of the three disparate “roles” they gain perspective and an understanding of the dynamic of change and the therapeutic process.

24. Background Details & Structure for Implementing the Socratic Team Case Supervision Model

25. Overview of the Socratic Team Case Supervision Method Background • What Is It? • A group learning experience for training in counseling and psychotherapy. • Supervision often leaves the presenter overwhelmed with suggestions and feeling as if they might not have faired well with their work. A more helpful format places responsibility on each of the Team members and generates more possible ways of working. • What Are The Learning Targets? • The counseling process has three (3) interconnected parts. Counselors need continuous skill improvement in each: • Assessment & Case Conceptualization: What seems to be the problem? Is it a crisis or chronic condition? Who does it effect and how? What is the social, historical, and cultural context? What are the client’s strengths, coping skills, risks and motivation for change? • Treatment Planning and Strategy: What needs to change and how? What are the steps that need to be taken? Is a particular theoretical orientation or hypothesize about the nature of the problem indicated? How do legal, medical, psychological, or medication issues factor into planning and the development of goals? Who needs to participate and what practical issues are likely to support or impede attendance or progress? • Interventive Tactics and Techniques: What specific tactics and interventions may help facilitate behavior change and prompt experimentation in new ways of being? How will work be directed and underlying issues, such as power-struggles, trauma, depression, and feelings of guilt and shame be remedied?

26. Background • Team Membership; Who Participates? • As a train-the-trainer model, the Team Supervision experience is intended for group case supervision, training on expert subject material and the apprenticeship and tutoring of counselors working toward clinical supervisor status. Membership includes the facilitator who serves in a coaching and proctor role (Lead Clinical Trainer), counselor supervisees and 1-3 facilitators-in-training working toward a level of confidence and competency to facilitate Team Supervision groups of their own using the same format. • Options for Team Member Composition • Homogenous Team: Counselors share a comparable level of expertise or role; ie. all LEs, all QMHPs, or all TDT staff • Mixed Team: Counselor have varied levels of expertise or roles and are pooled from various programs, such as ES, PSR, OP 4. What is the Team Size and Schedule? • Sessions run for 1. 5 to 2-hours, every two weeks, with a maximum number of participants of no greater than 20 • This scheduling accommodates 1 facilitator working with 2 groups, 1X each per week, for up to 40 counselors. When live practice (direct client therapy) is planned, the Team membership should not exceed 12, with 6-8 a preferable group size. 5. What Tools facilitate the Team Process? • Use of the Genogram for a) case conceptualization and b) as a common presentation tool. Cases material provides for instruction on a) process, such as how to transition parents into couple therapy and b) special topic subjects, such as working with addiction, domestic violence or paraphilia. This provides counselors variety in types of client profiles and syndromes. • Use of the Team’s group members for Cross-training and Brainstorming over treatment goals, strategy and planning. • Use of Role-play to actively rehearse and practice tactics and technique and maximize working in the here-and-now in session. In addition, the LCTs should provide periodic hand-outs and reading assignments on counseling theory, technique and special topic areas and schedule all meetings in a comfortable room with easel and markers and adequate space and chairs for role-play practice.

27. Role of the Facilitator Background As a Socrates Group or practicum group experience, the facilitator’s role is to create a classroom-like experience that challenges each clinician’s knowledge and skill level. A main objective of the experience is to practice and refine technique through role-play and re-enactment of session dealings The facilitator actively • Gatekeeps against “Advice-Giving” Prevents members from “advising” the presenter or others: No direct advice permitted or advice-giving under the guise of asking leading questions, asking for clarification or wondering and musing out loud • Provokes Critical Reasoning through “Socratic Questioning” Stimulates critical thinking by questioning and challenging group members as to how they would handle some particular aspect of the counseling session or intervention, then using comments from the current speaker to challenge another, and so on. • Trains Skill Refinement through Role-play and Re-enactment • Structures role-plays between members so they have an opportunity to practice and refine their skills to enact an intervention or tactic • Demonstrates technique by directly modeling its introduction, use and variations • Coaches member in “therapist” role by fine-tuning their verbal and behavioral interventions

28. Steps in The Team Case Supervision Process Background Supervision may leave the presenter overwhelmed with suggestions and feeling as if they might not have faired well with their work. A more helpful format places responsibility on each of the Team members and generates more possible ways of working. • Draw Genogram: The presenter is asked to draw the case genogram and indicate the following • The presenting problem and a history of its onset • Who lives at home/is involved in the presenting problem • Who has attended session and number of sessions to date • Their overall treatment strategy • Collect Info: The supervisor allows a period for information gathering (no case recommendations) by the members 1. Presenting Problem & Nodal Events • Case Outline: the Presenting Problem, including nodal events surrounding its recent onset, who participates and how (denotes purpose of problem). The sequence of behaviors surrounding the presenting problem (who does what when?) denotes who participates in maintaining the problem or symptom. • Treatment Overview: including previous therapy experiences and their outcomes, frequency and number of sessions to date, attendance pattern, regular participants and members refusing to attend or excluded. • Challenges and Quagmires: “sticky” places and “triggers” • Family Constellation (structures and sociodemographic profile data) • Family Atmosphere (dynamics within the relationship systems)

29. Background 3. Challenge Presumptions: The supervisor challenges the group, “round-robin” fashion, on how they would handle the case: • “You just inherited this case from the current counselor. Tell us, specifically, what you would do and how you would proceed?” or “You only had 5 sessions left to get to the goal of therapy; explain what you would do each session, session by session?” • “You’ve been asked to come into session as a consultant. What’s the 1 thing you would try to accomplish in 1 session and how?” • “Using the other members in a role-play, show us how you would make that (move, tactic, technique) happen.” General Questions to the Team • Why is the client/family seeking treatment at this particular time? Why this particular problem? What has changed? What if the Presenting problem was NOT the true problem but masked an underlying issue. What would it be? (purpose of symptom) • What would you do if a member critical to resolving the problem refused to attend or the client refused to have them attend? • Who has the power to bring the client(s) back? • How might they defeat the therapist or how might the therapist be most likely to fail? • If a co-therapist or consultant was brought in, how would you structure their role? What would wish for them to accomplish? • If you were supervising this case what direction/instruction would you give the therapist? • If you were to work from a different theoretical premise, what would you try and how would you approach the case? • What specific intervention would you wish to try or employ in the next session? 4. Button-Up: The supervisor wraps up the “feedback” and • Points to how best to work with issues common to this kind of issue, case or client; • Cautions about possible “blind spots” • Points to areas for clinical improvement and professional development

30. Background Sample Socratic Question Session Starters Engaging group members in a dialogue that helps them imagine new possibilities fosters impromptu clinical strength. The Facilitator challenges members, at random or “round-robin”, to explore how they might approach the presenter’s case: • Why is therapy being sought at this particular time? Why not a month ago or 6 months ago? What has changed? And, why this particular problem? Ask yourself, if the Presenting Problem was NOT the actual problem, what else -or who else, might be? • Who can identify a specific intervention they would wish to try with this case? Using group members for role-play show us how you might go about trying that. • Suppose you just got assigned this case. What would you do first? And then what? And then? And after, that what would you do? • Suppose you were trained in a different counseling style. How might you approach this case differently if it was Functional Family Therapy (FFT)? Emotionally Focused Therapy (EFT)? What about Dialectical Behavior Therapy (DBT) or Brief Strategic Therapy? • You learn that you only have 5 sessions left due to an unplanned relocation. What will you try, session by session, before you end? • What do you do when, during a one-on-one, the client drops the following “bomb” and ask you not to disclose it to anyone: a) “I have been seriously considering ending my life, have a specific plan, and don’t want to be talked out of it. I simply came to say Good-Bye!” b) “I’ve been cheating on my partner for several months, and I’m unsure if I want to remain with them or separate.” c) “ I was drinking and committed a serious crime (murder, arson, Medicaid fraud). Nobody knows, but it would definitely get me sent to jail?” d) “I’ve been having some disturbing, invasive thoughts about you, as my therapist. They’re very sexual in nature”. • Someone critical to the case refuses to attend session or is excluded from participating. How would you get them in? • If this case was to trigger your past or pose serious pitfalls or sand traps, what would it be? Who would make you feel that way? • See also Sample Socratic Questions (slide 13)

31. Background Socratic Method of Drilling Down Encourage possibilities by pushing one’s line of thinking “further down the road”. The following, simple line of questioning works very well. “Tell us what you would do?” “And then what would you do?” “And then what?” “And then what might you do?” “And then?” “And how would you go about doing that?” “And then what would you do?” “And then what?” “And then……….?”

32. Advanced Methods of Practice There are several formats for training in advanced methods of clinical practice. Three are highlighted in the following slides: The “Open Forum”; “Live Supervision Therapy”; and Multiple Family Therapy.

33. AP Advanced Practitioner Training Advanced Methods of Practice requires the facilitator or lead clinician to exercise greater mastery and control of the instructional experience. Live Supervision and Tasks Common to the Lead Supervisor • In Live Supervision, you are in charge and responsible for the outcome of therapy/treatment • Ensure everyone’s welfare, protecting the rights of the client as well as their safety • Ensure an agreed upon format and have everyone follow the same model of treatment • Decide, in advance, the extent of disclosure with clients of the team’s strategies and techniques • Be prepared to redirect, block, reframe, or side-line directives by non-lead counselors • Formats may include Supervisor/Counselor(s) alternating, Lead, Tag-team, Good Cop/Bad Cop • Require that all participants practice before the group • Require that supervisee is fully prepared to present their case • Do not permit mocking, horse-play or ridicule of clients or other counselors (either side of mirror) • Follow 1 or 2 cases from first session to termination, whether the supervisee sees a concern or not • Demonstrate: how to effectively interview (therapy is competent interviewing; J. Haley) • Demonstrate: how to move into the client’s emotional sphere, and then keep inching forward • Demonstrate: how to introduce in-session tasks and force work by remaining undistracted/on-task • Demonstrate how to introduce and reach agreement on the need to bring in critical participants • Demonstrate: how to push for the pain, -the worry, the guilt and shame, the anger, the sorrow • Demonstrate: how to button-up after each hard push and then at the end of a session

34. Advanced Method of Practice: “The Open Forum” AP Alfred Adler pioneered the “Open Forum”, a venue for inviting volunteers to engage in one-session problem-solving therapy in front of a live audience. Audience members are invited to step onto the stage to discuss their situation and obtain help from the therapist and others. The format was heavily replicated by others, including talk show hosts beginning in the 1980’s. - modeled by Dr. Robert Sherman, Author, Senior Fellow at the Adler Institute of NYC, and Chair of the Queens College Graduate Programs in Marriage & Family Therapy.

35. Advanced Method of Practice: “Live Supervision Therapy” AP Th Greek Chorus: May be Active or Silent observers; Lead Therapist may defer to Greek Chorus members as a sounding board, for opposing opinions, for emphasis, or to echo disparate voices. Members may also be called to step-in as Co-therapists or provide “Tag Team” therapy support. Th Unlike a 2-Way Mirror Therapy Room the Treatment Team, Lead Clinician(s) and Client(s) are all in the same room, sitting audience-style. The session may be highly choreographed or free-floating depending on its purpose, the approach, and the interests of the client(s). Client (s) Th Lead Therapist (s) Th Th The advanced Live Supervision format invites seasoned clinicians to join willing clients in the therapy process under the auspices of a Lead Practitioner. The Lead Practitioner structures session so as to draw on participating members individually or as a group (“Greek Chorus”). The format encourages broad experimentation across gender, age, racial and cultural lines, “tag team therapy”, and structured realignments, coalitions, and collusions. - modeled by Dr. Richard Belson, Director of the Family Therapy Institute of Long Island and long-time collaborator with Jay Haley.

36. Advanced Method of Practice: Multiple Family Therapy AP Multiple Family Therapy (Multi-family Therapy/Multi-Family Group Therapy) brings several families together, usually four to seven, who are struggling with a similar problem, condition or pathology such as Addiction, Eating Disorders, or Psychosis. Families work together and as separate units along and across generational, gender, and subsystem lines. It was first pioneered by H. Peter Laqueur, MD, at Creedmoor State Hospital, in NYC, in the early 1950’s.

38. Supplemental Materials Foundation Skills for Seasoned Case Managers, Residents, and Licensed Professionals

39. Rule-of-Thumb Rule-Out Differentiating Neurobiomedical from Psychological Symptoms 1. Ruling Out Neurobiomedical Issues

40. Parts of the Initial Consultation Ruling out the possibility of an underlying medical condition is a critical part of the initial consultation. It should also be prioritized whenever such a concern arises. When indicated, psychological testing and/or medical diagnostics should be employed. Therapists should note that 1) physiological symptoms can emerge from psychological distress and that 2) neurobiomedical conditions may express as anxiety or depression or other psychosocial impairments. Whether psychological or somatic in nature symptoms may be used by the individual or the relationship system to gain or regain control, mediate stress, avoid responsibility, or influence power and control. –see also section on Brain Injury and Post Trauma Distress. STEP 1: Global Assessment Standard instrument (ie DLA-20) or core realms of functioning, including orientation, SUD, depression/suicidality and unresolved conflicts, trauma, and points of anger. Ideally, a cursory review of the intrapsychic and interpersonal domains should be taken. STEP 2: Rule Out Exclude the possibility of a neurobiomedical condition (this Section) STEP 3: Challenge the Meaning and Purpose of  the Symptom or Presenting Problem • Track the beliefs and interpersonal transactions surrounding the Presenting Problem (PP), Identified Patient (IP) or Symptom(s); • Test the rigidity of the belief system, unbalance existing convictions and introduce new possibilities. • Return to the Presenting Problem (amplify if necessary), refocus on the goal of treatment and solidify agreement to work (Contracting). If commitment seems tenuous, seek agreement to return for “just one more session”, using it to shore up investment. • STEP 4: Contracting • Agreement on the preliminary goal of treatment, membership, frequency/cadence, importance of the therapeutic alliance, homework, and expectations surrounding work and pushing/encouraging change.

41. Symptom OriginationSymptoms originate from one of three global conditions Constructionism & Systems Perspective on Symptoms Origination and formation of enduring patterns of behavior, structures or syndromes that organize social interaction, mediate stress and provide adaptive response to change. When biomedical conditions acquire social significance, their expression may also emerge into psychological symptoms or tactics. • Symptoms are hardened patterns of interaction around which individuals express power and control. 2. Symptoms acquire history as they organize social behavior including how roles and rules of behavior become defined and how love, hate, need and want are communicated and shared. 3. Symptoms acquire Purpose, Meaning and Power Biomedical conditions may acquire psychosocial purpose. Prolonged Duress and Trauma -from disaster, loss, or betrayal, as well as from conflict and power struggles that result in misbehavior and victimization, result in psychological injury. Unresolved, this invariably leads to depression and anxiety which are fueled by Guilt, Anger, and Shame (GASh). The “injury” is to self-worth, to trust and intimacy; to one’s willingness to be vulnerable. Source or Cause Demetrios Peratsakis, LPC, ACS © 2018

42. Overview of the Rule Out Factors This simple C.A.T. Rule-of-Thumb Rule-Out should be a matter of course during the initial consultation for hormonal, neurochemical, structural injuries or irregularities of the body and brain. Additional concerns should be referred for psychological or neuro-medical diagnostic testing: “When in doubt, check it out!” • Congenital Brain Damage (CBD): genetic (pre-birth) or birth trauma • Acquired Brain Injury (ABI)/Neurological and Medical Illnesses: i.e.. stroke, tumors, aneurysms, thyroid disease, cancer, vitamin D deficiency, poisoning, exposure to toxic substances, infection, choking, complications due to alcoholism, substance misuse or medications. • Traumatic Brain Injury (TBI): head/skull injury to brain (accidents, sports injuries, falls, violence) What to look for: • Evidence of Progressive Decline in Cognitive Performance • Selectivity of the Impairment • Attitude toward Impairment by Caregivers • “The Miracle Question” Things to Consider • Formal Testing; Coordination with PCP or other primary healthcare providers • “Can Do” vs “Can’t Do” ; “Can’t Do” vs “Won’t Do” • Institutional Behavior • Chronic Duress/Severe Emotional Distress • Symptom Purpose and Intent* The idea that Psychological Symptom have purpose and meaning in social relationships is explored in the next several slides.

43. Rule-of-Thumb Screening Details Underlying medical conditions may express as psychological symptoms. The clinician must screen for disorders associated with injury or irregularities of the body and brain due to medical, hormonal, neurological/neurochemical, structural, congenital or brain injury conditions (C-A-T) and be prepared to recommend or require additional testing. “When in doubt, check it out!” • Look for Symptoms which make a Medical Illness more likely: • a change in headache pattern • visual disturbances, either double vision or partial visual loss • speech deficits, either dysarthrias (problems with the mechanical production of speech sounds) or aphasias (difficulty with word comprehension or word usage). • abnormal autonomic signs (blood pressure, pulse, temperature) • disorientation and/or memory impairment • fluctuating or impaired level of consciousness • abnormal body movements • frequent urination, increased thirst (possible symptoms of diabetes) or significant weight change • sudden onset of delusions or hallucinations not associated with delirium or dementia • allergic reaction or influence of alcohol, prescription/street drugs, poisoning or other substances and toxins • Look for Evidence of Progressive Decline in Cognitive Performance from a Previous Level: impairment to complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition, as documented by self-report, the expressed concern of a knowledgeable informant or observer, and supported by • Mental Status Exam (MSE) or standardized neuropsychological testing for detecting cognitive impairment, i.e.https://www.alz.org/media/documents/cognitive-assessment-toolkit.pdf • Medical examination (i.e.. blood test, cat scan, MRI, MRSI, MEG or diffuse tensor imaging) or • Testing:https://www.ncbi.nlm.nih.gov/books/NBK64110/ and https://www.ncbi.nlm.nih.gov/books/NBK64105/ • Selectivity of the Impairment: Is performance relatively consistent across similar tasks, functions or activities or does it appear to vary depending on interest, surroundings or participants? • Attitude toward Impairment by Caregivers: Does the behavior elicit compassion or anger? Do others view the actions as manipulative, belligerent or vengeful? Would caregivers agree that the individual “Can’t/Can Not” control their behavior or do they believe they simply “Won’t” for some reason? • “The Miracle Question” This was first employed by Alfred Adler as a method to distinguish between psychological and somatic conditions: “If I were to waive a magic wand and it got rid of this symptom you’re experiencing forever, what would be different?” If, as an example, the complaint was chronic back-pain and the response was “I would get a good night’s sleep”, it points to the possibility of a medical condition. If, on the other hand, the response appeared associated with some task in life, such as “I’d finally go back to school and finish my degree”, we might suspect a psychological purpose as the foundation. –See Related Screening Factors, next 2 slides

44. Related Screening Factors • “Can Do” vs “Can’t Do” It is important to distinguish between three, related terms to better assess the expectations we should hold of our clients as well as ourselves: Ability, one’s actual mental or physical skill; Capacity, one’s potential to develop or acquire a skill; and Capability, one’s unique fitness for a defined end or purpose. While there are rule-of-thumb ways to rule-out underlying medical conditions, a more precise assessment of complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition is difficult to ascertain without more comprehensive testing. Typically, the need to do so is expressed by family, friends and caretakers or more readily apparent during the course of treatment. The simple rule: so long as the individual retains capacity to learn, they can benefit from counseling. • “Can’t Do” vs “Won’t Do” Ambivalence, due to fear and apprehension, is not the same as unwillingness disguised as inadequacy, failure or sabotage. Can’t Do vs Won’t Do may initially be difficult to discern as the second often masquerades as the first. Many feign helplessness and despondency in order to place others in their service, escape responsibility, or burden then as an act of punishment and revenge. This is a passive-aggressive power-struggle for control. It does not mean the individual’s suffering is not genuine; simply that the guilt and shame bring a sense of legitimacy to the “nobility” inherent in the experience. When others feel manipulated and resentful, instead of compassion for the individual, it’s likely that “refusal” rather than “inability”, is at play. The power-play must be disengaged and redirected in order for treatment to proceed.

45. Related Screening Factors • Institutional Behavior To what extent has the individual been conditioned by their history with institutional care from hospitals, emergency departments, day support programs, social services departments, counselors and even jails? For many, the behavioral healthcare system has become their default social network, within which they have learned to accommodate their behaviors and beliefs in order to more effectively navigate their needed social supports. Is the behavior a learned response to the therapeutic context? It should also be noted that long-term institutional care, as well as chronic addiction problems, may adversely impact maturation and more age-appropriate social adjustment. 4. Symptom Purpose and Intent Symptoms are socially organized transactional patterns that acquire meaning, power and purpose. To understand their purpose, one need examine the outcome of the behavior and its social implications. What the symptom “accomplishes” is it’s intended outcome. This, rather radical perspective can provide great insight as to the reason for one’s actions and the goal of the behavior. Where the behavior has volition and intent, their exists a psychological component. Even symptoms of an underlying bioneuromedical condition can acquire social purpose and meaning. Where they compromise the individual or family’s ability to more effectively manage life’s tasks or adapt to change, counseling may be indicated. –see slides on Psychological Symptoms and their Purpose • Chronic Distress Physiological symptoms of chronic tension, violence or distress, may present as psychological problems, including disorganized thoughts, difficulty concentrating, irritability, fatigue, headaches, difficulty sleeping, digestive problems or changes in appetite, feeling helpless or a perceived loss of control, low self-esteem, loss of sexual desire, anxiety, frequent infections or illnesses.

46. 2. Understanding Psychological Problems

47. General & Specific Assessment Factors In order to achieve a more global, comprehensive assessment, internal, intrapsychic processes must be evaluated along with interpersonal, relational factors. A. General Assessment: Interpersonal • Global Functioning, Presenting Problem (PP) and Identified Patient (IP) • Relationships, Intimacy and Love Supports: partnership(s), current support system, Family of Origin, Family Constellation and Family Atmosphere (Genogram) • Maturation/Life Tasks: general adjustment and adaptation to developmental demands, change, and the tasks of life. Approach and attitude to life’s challenges, hardships and disappointments; ability to effectively resolve conflict, cooperate, and problem solving with others; movement toward the constructive, nonconstructive and destructive. • Open Discord, Conflict and Power Struggles (including detouring, coalitions and collusions) passive-aggression and temper tantrums) • Unresolved Trauma, especially Betrayals (including cut-offs, expulsions, abuse, rejection, affairs and abandonment) • Therapeutic Alliance: continuous monitoring of trust and collaboration B. Specific Assessment: Intrapsychic • The Self Concept: the combination of characteristic beliefs, values, moral convictions, and attitude toward Self, Others and the World that form the individual's distinctive perspective; understood through themes and patterns. • The Self Ideal: the fictitious goal or imagined state of excellence; “self-actualization” (Purpose & Meaning) • The Self Ideal vs the Self Concept • gauge or barometer of Self Worth/Self Esteem • points to avoidance and self-protection tendencies (Safeguarding)

48. Barriers to Healthful Maturation & Adulting Adulting requires successful reconciliation of the challenges that accompany Life’s demands. Problematic family dynamics, as well as unresolved trauma, can impede the maturation process and the individual’s ability to thrive. 1. Need to Avoid Blame & Shame • Problem accepting criticism and the risk of failure • Problem with responsibility and the risk of judgement by others 2. Problem with Empathy and Intimacy • Co-dependency; giving up the self as a method of pleasing others • Hypervigilance to critique and the opinion of others • Difficulty with trust, communicating and speaking true feelings, beliefs, and needs 3. Poor Self-esteem & Self-worth • Struggles with feelings of shame, inadequacy and worthlessness • Continual need for validation from others • Constant bouts of Guilt and Shame, which fuel depression and anxiety • Difficulty with appropriate assertiveness; having weak and/or inflexible boundaries • Self Concept continuously falls short of the Self Ideal • Problem with Anger & Aggression • Misuse of Anger, Power and Control to feel superior or more worthy than others • Passive-aggressive displays of revenge and blame to inflate false sense of vanity • Difficulty Adjusting to the Demands of Life and Life Events • Difficulty coping with pain or adequately reconciling adjustment to significant normative and paranormative changes associated with Work, Friendship, and Love. • Overreliance on avoidance strategies to blunt, mitigate or avoid pain.

49. Normalcy Requires Adapting to the Demands of Life Problems arise when individuals are unable to cope or adequately adjust to significant events in one of the three (3) main domains of life. Life Tasks 2) Life Tasks • Core domains of maturation and adulthood, including a) Work; b) Friendship/Community; c) Love (Alfred Adler; (Dreikurs and Mosak added “Self” and “Spirituality” as 2 additional Life Tasks). These are critical to self-identity and belonging as a social being. Details on next slide. 1) Life-Cycle Changes Normative and para-normative developmental stages or changes that occur across the life-span. Each involves series of relatively universal processes and tasks, such as young adults preparing to leave home, the birth of a first child, marriage, separation, divorce, and so on. (Monica McGoldrick) Life Cycle Trauma 3) Trauma • Psychological injuries due to significant hardship, conflict, loss, natural and manmade disasters, or human tragedies. Trauma may be cumulative; it diminishes are willingness to risk reinjury and adversely impacts our desire for intimacy and trust. Betrayal is the most insidious form of trauma. Unresolved, trauma results in depression and anxiety. Adulthood & Maturation: 1) reconciliation and adjustment to the significant changes created by Life Cycle events and processes; 2) relative success in negotiating the Tasks of Lifeand acceptance of the injuries and hardships imparted by others as well as Life’s misfortunes. Clinical Review: given the circumstances (age, type of and scope of injury, opportunity to remedy, et al), how well is one doing/should do?

50. The Tasks of Life The Tasks of Life are the Goals & Developmental Context of Socialization. “The human community sets three tasks for every individual. These three tasks embrace the whole of human life with all its desires and activities. All human suffering originates from the difficulties which complicate the tasks” - Rudolf Dreikurs, 1953 • Work: contributing to the welfare of others; the need to cooperate and build community, to belong and to share, for comfort, protection, resource development, and a means of pooling information and innovation (culture). –evolutionary advantage. This includes Occupational Choice (who we are moves what we choose to do or to be known by others); Occupational Preparation (being trained and training others builds worth and confidence); Satisfaction (daily and career goals that shape movement toward our final goal or self-ideal); Leadership; Leisure; and Socio-vocational (relationships with colleagues is an important part of community). 2. Friendship: building social relationships with friends and relatives; Cohesion, attachment and bonding. The creation and expansion of culture (innovation, information) -evolutionary advantage. It includes Belonging, the sense of being accepted and cared for by others, of being valued, is the fundamental driving force of humankind, and Transactions, how we interact with others. These are directly responsible for the abatement of one’s sense of vulnerability and inferiority. • Love:. Intimacy, bonding, establishing (sexual) intimacy with a partner and the foundation of procreation and parenting. This is the most demanding and rewarding of adult relationships. It includes Sexual Sex Role Definition (What is Man? A Woman?); Sexual Sex Role Identification (Masculinity; Femininity); Sexual Development (puberty, secondary sexual characteristics, menstruation, masturbation, et al); and Sexual Behavior. • The Self Task: Survival; Body Image; Opinion; and Evaluation • The Spiritual Task: Relationship to God; Religion; Relationship to the Universe; Metaphysical Issues; and Meaning of Life The Tasks of Life are shaped by and, in turn, shape our Private Logic, which molds the Style of Life or our movement toward our Self Ideal, our Final Fictional Goal. We can gain insight into the Private Logic and Life-Style, by examining the themes that shape our ideas, behaviors and emotions. Each is a reflection of both our immediate goals and our final, fictional goal. We can always see “purpose” in the activity and its intended outcome.