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Fall 2015
Resilience

Success Counseling: A Tool for Aging Life Care Professionals™ / Care Managers

About the Authors

D. Barnes Boffey, EdD has been working in the field of Internal Control Psychology since 1977. He was a Senior Faculty member at both the William Glasser Institute and the International Association for Applied Control Theory and has taught at the University of Cincinnati, Dartmouth College, and in many other adjunct roles. Dr. Boffey is currently the Director of Training of the Aloha Foundation, an organization whose total philosophy is based on Success Counseling. Dr. Boffey has written two books (Reinventing Yourself and My Gift in Return) and multiple articles regarding Success Counseling

Jennifer Pilcher Warren, PHD, CMC was awarded her doctoral degree in Gerontology from the University of Massachusetts in Boston. Her professional experience has focused primarily on care and housing arrangements for elders with Alzheimer’s disease and related dementias, including policy and fundraising work for the Alzheimer’s Association of Eastern Massachusetts, the Alzheimer’s Association of Utah, and the Massachusetts Association of Older Americans. She currently sits on the board of the New England Chapter of the Aging Life Care Association™ and the Publications Committee for the Aging Life Care Association™. For seven years, Ms. Warren was affiliated with Hearthstone Alzheimer Care Assisted Living programs in Massachusetts and New York, where she held a number of management positions. For 8 years, Ms. Warren worked both as a Geriatric Care Manager and as the Director of Operations for AZA Care Management of Boston. She currently holds the position of Executive Director of Care Management for Overlook C.A.R.E., a non-profit Geriatric Care Management practice with offices located in Hingham, Dedham, Plymouth and Charlton, MA.

D. Barnes Boffey, EdD & Jennifer Pilcher Warren, PhD, CMC

Introduction

Success Counseling is an approach to working with our clients which focuses on the individual’s ability to evaluate themselves. It is a process that assists the client to ask hard questions and increases awareness of how he/she feels, how these feelings effect decisions they make, and the results of these decisions. The goal is to improve the client’s ability to be an independent problem solver. This article discusses how the principles of Success Counseling can be applied by Aging Life Care Professionals™ / care managers as a practical approach to helping our clients. We believe that by using the Success Counseling approach, care managers can help clients uncover their strengths and foster increased feelings of effectiveness, happiness and well-being. Success Counseling can create a “resiliency perspective” which changes how clients see the world and their own behavior, leading to more effective action and a greater degree of self-worth and hope.

Success Counseling is based on the theories of Dr. William Glasser (Choice Theory) and William Powers (Perceptual Control Theory). Both of these theories posit that people who believe that their happiness and well-being are a function of external factors will focus on trying to change those external factors to achieve happiness. In contrast, people who believe that a variety of factors are within their own ability to change (expectations, perceptions, and actions) can maintain their balance and improve their situations even when they previously felt powerless. Success Counseling also posits that behavior is not a matter of linear causality (stimulus leads to feeling which leads to action) but circular causality (expectations affect emotions which affect perceptions which affect expectations) – that we actually create our emotions rather than emotions simply happening to us. One of the fundamental aspects of this type of counseling is that it uses the process of self-evaluation to help the individual consider how effective their approach is to dealing with common losses and challenges associated with aging. This is the essence of resilience: positive adaptation in the face of loss and change.

As Aging Life Care™/ care managers, when we are faced with a cognitively intact client who is struggling with the common issues of aging such as death and dying, resisting accepting needed care, driving cessation or difficult family dynamics, what do we have to offer? Can we help that client regain a sense of control and promote good decisions even when choices are limited? Widening the lens from which our clients view the world may open up several new possibilities that may replace loss with potential gains.

Theoretical Foundations of Success Counseling

Internal vs. External Control Theory

External control psychology underlies most thinking about human behavior in our major societal institutions: school, family, marriage, corrections, and management. A major belief in these institutions is that we do what we do because of how we feel (“I felt depressed so I’m sitting here doing nothing!” or “I felt angry and that’s why I yelled at him.”). We tend to believe that our feelings drive our behaviors.

A second major belief of external control psychology is that I feel the way I do because some person, place, or thing makes me feel that way. (“My aide made me angry,” or “Other residents make me feel stupid.”) These two beliefs create a “victim” mentality: others cause both our happiness and sadness, and therefore we try to control the behavior of others so we can feel the way we want to. (“If I can just get her to stop doing that, then I wouldn’t be so upset all the time.”) A typical question you hear based on an external control perspective is “How are we going to make this client do….?”

Internal control psychology is based on the belief that what goes on around us is simply information, which we can choose to perceive as positive, negative, or neutral. If someone calls me a name, I can choose to feel angry, sad, or sorry for that person’s lack of understanding, grateful I am not them, or any of a number of other emotions based on my perception. Internal control psychology tells us that our emotional pain comes not from the circumstances of our lives, but primarily from the way we deal with those circumstances.

Gaining skill in choosing our feelings and thoughts is not an easy process; it takes time, energy, and good role models. Aging Life Care Professionals / care managers who use this approach can help clients learn to face life through asking a new set of questions. When we are having difficulty, the question isn’t “What is making me feel bad?” but “How do I feel in this situation?” and then “How would I like to be feeling?” As the question changes, the responsibility shifts to how we deal with the information we are receiving rather than feeling like a victim of that information.

This approach consciously rejects victimizing others or ourselves, and supports learning to be responsible (response-able) for how we act, think, and feel. The Success Counseling approach allows our clients to realize their potential in choosing their perceptions and emotions, rather than feeling victimized by their circumstances.

EXAMPLE: Questions based on the external control or the internal control model

Your client is unhappy after moving to a facility. In an external control model, the questions are “Why are you unhappy here?” and “What’s making you feel unhappy?” In an internal control model the questions are framed differently: “Do you want to be unhappy?”, “Can you imagine being happy even though you are not in your house?”, “Do you want to be enjoying living here rather than feeling sad all the time?”

The internal model questions are based on the assumption that our emotions are coming from the inside out (internal), not from the outside in (external). If we treat our clients as if they have more control over their emotions than they believed possible, we can help them learn to exercise that control to increase their choices.

Internal Instructions

Another aspect of Dr. Glasser’s model of choice theory, is that human beings are born with basic psychological/spiritual instructions.

As human beings, internal biological instructions to eat, sleep, and maintain a certain level of liquid in our bodies are built into our physiology. If we follow these instructions by eating good foods, sleeping a reasonable amount, and varying our liquid intake to match our activities, we feel healthy and in balance. But if we don’t follow them — eating the wrong foods, not sleeping enough, or drinking too much or too little liquid — we experience an “internal signal” of hunger, nausea, fatigue or thirst which lets us know we are out of balance. We do not choose these signals; they are a physiological consequence of not following our internal instructions.

Choice theory posits that we also have internal psychological/spiritual instructions and we also experience painful signals if they are not followed. In our Success Counseling model these basic internal instructions are to be loving, to be powerful, to be playful, and to be free. In an external control model these would be expressed as the need for love, power, fun, and freedom. Viewed this way, these qualities become something we need to get or have, like commodities. External motivation drives people to search outside themselves to “have more freedom,” or “get more love” in their lives, or “have more fun,” or “search for power and recognition.”

Examples of the expression of needs when based on the external control model

“My son doesn’t give me enough freedom.”
“I’m feeling lonely; I need people to love me more!”
“That’s not fun — I need to have more fun things to do in my life.”
“If I could just go back to work, that would make me feel more important and powerful.”

By viewing love, power, fun, and freedom as instructions “to be,” we spend less time looking outward and more time looking inward at who we are and how we can be the people our instructions urge us to be. When we are able to follow our internal instructions, even in difficult situations, we begin to esteem ourselves and sense a new freedom and power in our lives.

The instruction to “Be Loving” is an urge to connect, to belong, to feel compassion for others, and to forgive. Being loving is easy in situations others are doing what you want and giving you the attention and love you desire. But being loving is more difficult if someone is mad at you, lets you down, treats you poorly, or does not do what you want them to do. In an external motivation model, we blame the people who are doing these things and see them as the cause of our pain.

The internal motivation model says that our pain is created because we are having difficulty being loving when others are acting this way. To wait for others to change so that we can love them is be a source of endless frustration and disappointing relationships.

For example, after an argument with an adult child, we could ask a client, “Do you want to be mad at your daughter or do you want to figure out a way that you can feel calmer and less angry?” We are inviting the client to consider the alternative of changing his/her way of perceiving the situation.

“Being Powerful” means having a voice, staying strong in difficult situations, being worthy, having self-respect, and having impact on the world. It is easy to feel powerful if everyone is listening to you and giving you what you want. It is harder when others do not value you as much as you think you deserve. In the external model, we might say, “That person makes me feel worthless,” or “How can I feel good? I can’t do anything anymore.” Using Success Counseling, we would invite the client to create his/her perception by asking, “Would you like to spend your time feeling good about what you can do or bad about what you can’t do so well?”

“Being Playful” is the ability to have fun regardless of your surroundings. Little children can have fun with a stick and a juice can. They create their play; they don’t wait for it to happen. Too often as we get older, we wait for external circumstances to create pleasure. Internally motivated playfulness comes from viewing each situation with curiosity, whimsy, and an openness to new perceptions. Hiking is fun for some people and for others it is not, but it is not the hiking that is fun or not fun; it is the attitude with which we hike that creates the pleasure.

Finally, “Being Free” is our ability to maintain a sense of autonomy and choice. People following their internal instruction to be free are able to see choices, to see the glass half full, and to think about “freedom to” and “freedom in.” People who are trapped in the external mind-set are always worried about “freedom from” and ask themselves, “How is this making me feel?” People who are being free are more likely to ask, “How do I feel about this situation?” and even more importantly, “How do I want to feel about this situation?”

If we don’t follow our psychological/spiritual instructions, we feel internal signals — loneliness, powerlessness, boredom, or feeling trapped — that inform us of that fact. When people who understand their internal instructions feel lonely, for example, they do not wait for others to love them. They look for others to love. They call a friend, they pat the dog, or they give a gift. As they take these actions, they begin again to be loving, and the loneliness disappears. When they feel bored, they don’t wait for something to entertain them, they create their fun by beginning to be playful in the situation at hand.

“Quality World” and Pictures

Success Counseling also uses Dr. Glasser’s concept of the “Quality World”. This is a metaphorical way of saying that, throughout our lifetime, we select what we believe to be the best pictures from our life and store them as our Quality World. These pictures are how we attempt to actualize how we are loving, powerful, playful, and free. We may not always be able to attain our desires or measure up to our ideals, and over time, we may adjust our pictures to be more realistic or effective. But, at any given time, our pictures of what we believe get us what we want and provide the day to day foundation for our behavior.

These pictures of our Quality World are very personal to us and in some instances may have little to do with reason or rationality. For example, our picture of a holiday dinner together with our extended family may include everyone getting along, very specific foods, a specific length of time, a specific feeling, and specific people. Our ideal picture may have little or nothing to do with what actually occurs at that meal, but we continue to carry that picture anyway. This attachment to our pictures can be a barrier to flexibility and therefore resiliency.

Our Quality World contains the knowledge that is most important to us as individuals, the things that define how we wish to be. Anytime we succeed in satisfying a picture in our Quality World, it is enjoyable. On the other hand, if we fail to satisfy a picture in our Quality world, it is painful. People define reality in the way that works best for them. We see the world, not as it is, but the way we want to see it. The discrepancies between our Quality World picture of what we want and who we want to be with the picture of what we actually have and who we actually are creates the stress in our lives. When the pictures don’t match, we experience various degrees of frustration and upset. How we deal with the tension between what we want and what we get will for the most part determine the quality of our happiness.

In Success Counseling we recognize that when we can’t change the conditions within which we find ourselves, our happiness and freedom become contingent on our ability to change ourselves. If we are unable or unwilling to make that change, we inevitably become victims of our own pictures. It is frequently the case that our clients have outdated pictures in their Quality World that is making them miserable because the picture is so different from their current reality. For example, an older gentleman could be unhappy because driving a car is a picture in his Quality World long after he has the physical or visual capacity to do so safely. However, it is painful for him to let go of this picture as it represents freedom and independence. Further, as you age, most people experience continual losses of people, independence, occupations, roles and abilities – in other words, a constant death of the idealized pictures you have of yourself throughout your lifetime.

Success Counseling: Putting the theory into action

As care managers, it may be difficult to envision how to help your clients who are experiencing stress or unhappiness due to obsolete pictures in their Quality Worlds. Based on Dr. Glasser’s theory, the way to help people to be happy and make change in their lives is to identify what is in their Quality World and then try to support it. However, it may be difficult to gain the trust necessary to have a client share their Quality World because they are afraid that others may not support their picture of the world. As care managers your goal should not be to force a client to change their picture of their world but rather to help our clients create new pictures of a Quality World that can be achieved.

Example: Past Pictures/Current Life

An elderly male client may believe that power and recognition primarily come from status and career accomplishment, while at this point in his life his working career is over and his power in the marketplace is severely diminished. Another client’s pictures of fun include being able to run a half marathon, or her picture of freedom is built on the idea of doing anything she wants, anytime she wants. Using the Success Counseling approach, your role as a care manager is to challenge your clients to grow and redefine what they believe to be quality through creating new pictures for their life with instructions that are viable today.

Success Counseling uses a process of self-evaluation to guide the client through choosing how they want to experience the world. Success Counseling is focused on helping the client do the work, assisting through the thought process that allows her to arrive at a next step and to move forward. The basic rule of Success Counseling is “Ask, don’t tell”. In Success Counseling asking the right questions makes the client an active participant in the problem solving process and therefore in control over her life.

The Essential Questions

Success Counseling uses a series of questions, rather than statements, throughout the counseling process, in concert with building a relationship of trust with the client so they can be honest and feel safe. The relationship we build with the client rests on a foundation of being loving, powerful, playful and free. We don’t just talk about those qualities; we put them in action in the relationship. When the relationship has the strength to handle honest interaction, we can them begin to ask a series of questions to build resilience and the ability to change that is the goal of Success Counseling.

1st question: What do you want?
Alternative Questions: What do you want to do? What do you want to feel? Who do you want to be?

You start by asking the client: What is your picture? What is your idea of where you would like to be? With these questions you are trying to understand the client’s Quality World and where the discrepancies lie that may be at the foundation of their unhappiness. The pictures that are in the client’s Quality World are what drive their behavior on a daily basis and what leads them in their lives. The question: “What do you want” is a powerful way to begin to understand the client’s pictures. Too often we offer suggestions, judgments, or ARTICLE 10 TABLE ONLY_GOES IN MID OF Q1solutions rather than starting with understanding what is most important to the client.

With many traditional approaches this is where the client’s contribution to the conversation ends. Once we have found out what the client wants, we utilize our many resources and strategic approaches to apply solutions we believe are likely to work. For example, you may respond by:

  • Validating the client’s feelings and redirect the conversation
  • Saying “Well, then why don’t you just ________”
  • Giving advice and guidance to the client’s caregivers and family members about which approaches should be used to improve the client’s quality of life

While this is a worthwhile, sometimes effective and seemingly efficient approach to problem solving, what it doesn’t do is engage the client in the process of identifying their own needs and working collaboratively on solutions. Moreover, it does not leave the client feeling empowered and free.

2nd Question: What are you doing to get what you want?
Alternative Questions: What have you tried? What behaviors have you tried to get what you want?

Success Counseling suggests that in order to engage the client in evaluating themselves and generating their own solutions to problems, the self-evaluative process needs to go deeper. For this reason, the second question involves asking the client what they have done so far to try and solve the problem or to try and feel better. The focus on self is what carries you through the questioning process. Sometimes the answer to the second questions is “nothing” or sometimes the client will tell you what they have done.

3rd Question: Is it working? Has it been as effective as you hoped it would be?

This next question is not one of right or wrong, but rather a question of effectiveness. There is an old Hawaiian saying, “effectiveness is the measure of truth”. What we are essentially doing is holding the mirror up to the client and saying, “Ok, you have tried to do this, is what you are doing working?” This is the self-reflective and self-evaluative part of the process.

At this point, it is important to help the client look at the overall picture of what he wants. If a client thinks what they are doing is working, she will not change their behavior.

4th Question: What do you see as your choices now?

Again, you may be tempted to begin pointing out what you see as the choices for resolution. In Success Counseling, however, we ask the client to come up with the answers. Once the client offers their ideas, then you can follow up by asking “If I had some other choices you hadn’t thought of, would you like to hear them?”

“What do you see as your choices now?” is not the same as asking, “Ok, what are you going to do?” “What do you see as your choices now?” is a divergent question looking for options; “Ok, what are you going to do?” is a convergent question looking for a decision. Using this method is respectful, thoughtful, and it allows your client to be in charge during the process. Most of the time, your client will want to hear your choices. Once you have a list of his ideas and your ideas, you are ready for the next question.

5th Question: Would any of these choices be better than what you are doing now?

Typically we might ask, “Would any of those work?” By “work” we are asking the client to solve, finish, or resolve the problem. Rather, we want to ask our client a comparative question – “Here’s where you are, here’s where you want to be, my job is to help you get closer to where you want to be. If one of those choices would be better – are you willing to take the next step?” If the answer is yes, you are ready for the last question in the process.

6th Question: What’s your next step?

Notice you are not asking the client “What is your resolution?” You are not asking for the whole solution, just the next step.

These questions are not necessarily linear, this is not a one stop question process, but should be used in a circular manner. Some of the questions you may have to ask over and over if you have a resistant client. You may have to come back to “Is it working?” over and over again until you can get a client to admit the ineffectiveness of what they are doing or break through an alibi or excuse.

However, like adolescents, older adults may choose to continue to be miserable or continue their behavior. Sometimes there are payoffs of sympathy, help, closeness and resources that we receive if we stay in the victim role. If your client wants to be unhappy, you will not be successful in getting them to change. In this case, you will need to find a way to help them improve their lives while staying as unhappy as they want to be. Paradoxical, but effective.

Success Counseling Example: Mr. Smith

Description: Mr. Smith has been refusing to accept care in his home. His adult daughter has been hounding him to accept care as he has fallen several times. He agrees to accept care and then fires the home health aides that his daughter sends to the house. In desperation, the daughter has hired you to try and work with her father to see if you can uncover what is going on and help him to accept assistance.

Question 1

Mr. Smith: Who are you and why are you here? Did my daughter send you?
Care Manager: I am an advocate that works with older folks to help them meet their goals.

Mr. Smith: Oh, I bet you do. I know, you are just one of my daughter’s henchmen.

Care Manager: Mr. Smith what is it that you want?

Mr. Smith: What do you I want? No one asks me that question, they just tell me what to do. Let’s see….. I want to stay in my home until I die. I want my daughter and everyone else to stop pestering me.

Care Manager: Is there anything else?

Mr. Smith: Well, yes, I would like to visit with my daughter like we used to…..watch the baseball game together….not argue…

Question 2

Care Manager: So what have you tried so far to get what you want?

Mr. Smith: Well, I have sent everyone away and told everyone to stop bothering me.

Care Manager: Anything else?

Mr. Smith: I have been trying harder to do everything myself so I can show my daughter I can do it.

Question 3

Care Manager: And how has that been working? Are you getting the independence and relationship you said you wanted?

Mr. Smith: Well, yes and no. I mean I have been able to get everyone to go away….and I have been able to manage by myself most of the time, except when I fell and broke my arm….., now I have someone here every damn minute…

Care Manager: So it sounds like you were able to fire the home health aides, but you aren’t alone at home and things aren’t so good with your daughter, so did this work?

Mr. Smith: Well, no.

Question 4

Care Manager: So, what do you think your choices are now?

Mr. Smith: Well, I don’t know, maybe I will have to try harder to do things on my own.

Care Manager: That is one choice.

Mr. Smith: Or maybe I should just give up and die in this awful place.

Care Manager: That is another choice.

Care Manager: Ok, any other choices?

Mr. Smith: I don’t know. I could talk to my daughter. I could call the agency we were using before.

Case Manager: Or you could just keep doing what you’re doing…..

Mr. Smith: no, that’s not working.

Care Manager: If I had some other choices you hadn’t thought of, would you like to hear them?

Mr. Smith: I guess so.

Care Manager: One choice would be to come up with a plan so that someone could check on you during the day, and help you with certain things, but they wouldn’t have to be there all day.

Another would be to tell your daughter how grateful you are for her help and that you want to watch the game with her rather than fight.

Another choice would be to ask your daughter if there is a way she would feel that you are safe without having people here all the time… maybe one of those house monitoring systems.

Another would be to check in with your daughter a few times a day.

Another would be to ask her over for dinner or ice cream so it’s more festive and less confrontational.

Question 5

Care Manager: Ok, now we have a list. Would any of these choices work better than what you are doing now?

Mr. Smith: I guess I could check on those camera things where they show the house but I don’t know how expensive they are?

Care Manager: Well, one step could be to check on that and ask your daughter for help checking on it. Would that feel like a step in the right direction?

Mr. Smith: Yes, and I like the idea about ice cream too. We always used to put lots of stuff on our ice cream and laugh like kids when we ate it.

Care Manager: And can I ask you if you think the three of us talking together might be a good idea too?

Mr. Smith: Sure, I think she thinks I’m fighting her. I just don’t want to feel like I’m 10 years old with my mom hounding me all the time.

Question 6

Care Manager: Ok, are you ready to make that your next step?
At this point in the counseling session, you should get very specific about how to get the ice cream and what toppings, when the conversation might happen with his daughter, and how to get information about a home monitoring system. You will not have solved the problem fully, but you will have headed down the road in the direction of his wants.

Conclusion

In Success Counseling, self-evaluation is much more important than the evaluation of others, because it is self-evaluation that leads to change. Success Counseling shifts the responsibility and the thinking to the client. This process forces the client to ask himself hard questions and makes him aware that he can influence how he feels and the results of his decisions. With repetition, Aging Life Care / care managers can get their client to utilize this process themselves for independent problem solving. By participating in Success Counseling, your clients will become more confident in solving problems with you or independently, which will have a significant impact on his resilience, confidence, self-esteem and ability to handle change.

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