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One More Montana Love Workshop Promo: You’ll Get to Learn from the Amazing Dr. Jon Carlson

Hello Mental Health Professionals.

I’m writing to remind you to register for our Spring LOVE Workshop series through the Department of Counselor Education. Although the WHOLE conference includes content that can be useful in your professional and personal lives, in particular, I want to point out that, for the Friday, March 20 date we have the honor of hosting and learning from Dr. Jon Carlson and it’s not often we get someone with the immense experience and expertise of Jon Carlson.

If you don’t already know who Jon Carlson is, here’s an official bio on him:

Jon Carlson, PsyD, EdD, ABPP is Distinguished Professor, Psychology and Counseling at Governors State University and a psychologist at the Wellness Clinic in Lake Geneva, Wisconsin. Jon has served as editor of several periodicals including the Journal of Individual Psychology and The Family Journal. He holds Diplomates in both Family Psychology and Adlerian Psychology. He has authored 175 journal articles and 60 books including Time for a Better Marriage, Adlerian Therapy, Inclusive Cultural Empathy, The Mummy at the Dining Room Table, Bad Therapy, The Client Who Changed Me, Their Finest Hour, Creative Breakthroughs in Therapy, Moved by the Spirit, Duped: Lies and Deception in Psychotherapy, Never Be Lonely Again, Helping Beyond the Fifty Minute Hour, How a Master Therapist Works and Being a Master Therapist. He has created over 300 professional trade video and DVD’s with leading professional therapists and educators. In 2004 the American Counseling Association named him a “Living Legend.” In 2009 the Division of Psychotherapy of the American Psychological Association (APA) named him “Distinguished Psychologist” for his life contribution to psychotherapy and in 2011 he received the APA Distinguished Career Contribution to Education and Training Award. He has received similar awards from four other professional organizations. He has also syndicated the advice cartoon On The Edge with cartoonist Joe Martin. Jon and Laura have been married for forty-seven years and are the parents of five children.

Obviously, Jon Carlson is highly acclaimed within both the Counseling and Psychology disciplines and I don’t think you should pass up a chance to see him live in Montana.

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There are now two ways to register for the WHOLE conference or for a single session.

1. You can print and fill out the registration form that follows and mail it in the old fashioned way, or
2. You can go online and register and pay through the Children’s Museum website. Go to: https://www.childrensmuseummissoula.org/ and scroll down about half a page.

If you decide to pay online and you don’t want to fill out and mail the registration form, drop me an email at: John.sf@mso.umt.edu and let me know you’re signed up and I’ll make sure we have a form ready for you to fill out at the workshop so you can avoid having to hassle with mailing it.

Finally, for those of you have read this far and want to know more about Jon Carlson’s presentation in Missoula, here’s a description in his own words:

Adlerian Brief Couples Therapy

There has been considerable debate and negative press in recent times over brief therapy and whether or not it is in the best interests of clients. Most therapists/counselors fail to realize that most clients want brief treatment. They want to get help as soon as possible. People do not have unlimited time or money to spend on therapy no matter how valuable counselors and therapists think their services are. Most want help and are not looking for a paid-for friend.

Another truth is that most therapy is brief as clients attend treatment for usually less than 6 sessions with one being the modal number. Managed care companies are quick to remind us that most gains in therapy occur early and tend to diminish as treatment continues. It would unprofessional to act as if some clients cannot benefit from long term treatment. There are conditions in which longer treatment is necessary but this is the exception and not the rule.

Most clients really do not want to be seeing therapists. They wish there lives worked and that they were “normal.” It is important for effective therapy to understand that this is the case and to provide as efficient a treatment as possible.

This program will focus on how to do brief therapy with couples. I will talk about brief therapy from an Adlerian theoretical orientation as well as the skills of a healthy relationship. The participants will also be able to see the process applies as I work with an actual couple and help them resolve some of their current challenges.

That sounds pretty cool to me and so I’m planning to be there.

That’s it for now. Have a great rest of the week and I hope to see you at one or more of the workshops.

Sincerely,

John SF

John Sommers-Flanagan, Ph.D., Professor
Department of Counselor Education
Phyllis J. Washington College of Education and Human Sciences
University of Montana
32 Campus Drive
Missoula, MT 59812
406-243-4263 (office); 406-721-6367 (cell)
John.sf@mso.umt.edu
Johnsommersflanagan.com

And here’s a photo of Dr. Carlson

JC 2010c

 

 
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Posted by on February 18, 2015 in Uncategorized

 

How to Talk so Parents will Listen: Strategies for Influencing Parents

Last June I had a chance to go to Chicago to be filmed doing three professional THERAPY TALKS. It was a challenging situation; just me and a camera and a few production folks. One of the TALK topics focused on how to work effectively with parents. As it turns out, this video and others I’ve done with Microtraining are now available at their website: https://www.academicvideostore.com/publishers/microtraining (you have to search for Sommers-Flanagan).

Here’s the text, more or less, from the “How to Talk so Parents will Listen” TALK.

When I talk with large groups about parenting, I like to begin with a survey. I ask: “How many of you ARE parents?” Of course, nearly everyone raises his or her hand. Then I ask a follow up: “How many of you WERE children.” At this question some participants laugh and a few raise their hands and others joke that they’re still immature.

This reason I start with this survey is because if you’re a parent, you know that being a parent is an amazing and gratifying challenge. You also know that it’s 24-7; and you know it doesn’t end when your child turns 18. You’re a parent for life. And if you WERE a child, and all of you were, then you know how important it is to have a parent or caretaker who makes it perfectly clear that YOU ARE LOVED. But there’s more. If you were a child, then you also know how important it is to have a parent who not only loves you, but who is skillful . . . a parent who is dedicated to being the best parent possible.

Plain and simple: PARENTS NEED SKILLS FOR DEALING WITH THEIR CHILDREN IN THE 21ST CENTURY. And learning to be a better parent never stops.

Once upon a time I had a mom come consult with me about her five year old son. She said: “I have a strong-willed son.” My response was to acknowledge that lots of parents have strong-willed children. She said, “No, no, you don’t get it. I have a very strong-willed son, let me tell you about it. Just the other night, I asked him to go upstairs and clean his room and he put his hands on his hips and said, “NO.” So I said in response, “Yeah, yeah. He sounds very strong willed.” And she said, “Wait. There’s more. I asked him to clean his room a second time and he glared and me, and said “NO. YOU WANT A PIECE OF ME?” Then she told me the real problem. The problem was that, in fact, she did want a piece of him at that particular point in time and so she grabbed him and hauled him up the stairs in a way that was inconsistent with the kind of parent she wanted to be.

This is one of the mysteries of parenting. How can you get so angry at a small child whom you love more than anything else in the world?

Parents are a unique population and deserve an approach to counseling that’s designed to address their particular needs. In this talk I’ll mostly be using stories to talk about:

a. what parents want for their children
b. what parents need in counseling
c. and how professionals can be effective helpers.

Most parents want some version of the same thing: To raise healthy and happy children who are relatively well-adjusted. But what do parents need in counseling. WHAT WILL HELP THEM GET WHAT THEY WANT?

First, parents need empathic listening. They need this big time. Our American culture puts lots of social pressure on parents . . . It’s implied that parenting should be easy and all parents should want to spend 24-7 with their child in an altered state of parental bliss. But this isn’t reality and so we need empathy for the general scrutiny parents feel in the grocery store, at church, on the playground, and everywhere else.

But they also need listening and specific empathy: like in the situation where the mom wanted to tell me about her 5-year-old son. She had specific information to share and it was really important for me to take time to listen to her unique story about her son who, unfortunately, may have seen too many Clint Eastwood movies.

Parents come to counseling or parent education feeling simultaneously insecure and indignant. They feel insecure because of the scrutiny they feel from their parents and in-laws and society, but they also feel indignant over the possibility that anyone might have the audacity to tell them how to parent their children. As professionals, we need to be ready to handle both sides of this complex equation.
Another thing parents have taught me over the years is to never start a parenting session by sharing educational information. You should always wait to offer educational advice, even when parents ask you directly for it. When they do ask, let them know that your ideas will be more helpful later once you get to know what’s happening in their family.

This leads us to the second crucial part of what parents need in counseling. They need collaboration. We can’t be experts who tell parents what to do, instead we have to recognize that parents are the experts in the room. They’re the experts on their children, on their family dynamics, and on themselves. If we don’t engage and collaborate with parents, very little of what we offer has any chance of being helpful.

Parents also need validation to counter their possible insecurity. We call this radical acceptance or validation and it involves explicitly and specifically giving parents positive feedback. We do this by affirming, “You sure seem to know your daughter well.” And by saying, “When I listen to how committed you are to helping your son be successful in life, I can’t help but think that he’s lucky to have you as a parent.”

And so we begin with empathic listening and we move to collaboration and we make sure that we offer radical acceptance or validation and we do all this so we can get to the main point: providing parents with specific parenting tips or guidance.
And there are literally TONS of specific parenting tips that professionals can offer parents. Most of the good ones include four basic principles:

First, getting a new attitude – because developing parenting skills requires a courageous attitude to try things out.

The second one involves making a new and improved plan. Because a courageous attitude combined with a poor plan won’t get you much.

Third is to get support when you need it. Parenting in isolation is almost always a bad idea.

Fourth, underlying all tips there should be the foundation of being consistently loving.

I’d like to tell two parenting stories to illustrate all of the preceding ideas.

This first story is about a parenting struggle I had. I share it for two reasons: One is that it’s a great example of the need for parents to make a new plan to handle an old problem. And two, often it’s good to self-disclose—but not too much—when working with parents.
When my youngest child was 5-years-old, she ALSO was a strong-willed child. I vividly recall one particular ugly scene on the porch. It was time for us to leave the house. But we lived in Montana and there was snow and my daughter needed to put her boots on. Funny thing, she was on a different schedule than I was. This created tension and anger in me. And so I got down into her face and I yelled GET YOUR BOOTS ON! And her eyes got big and she did. Later that evening I was talking with my wife and she saw the scene and she said to me, “I know John, that’s not the kind of parent you want to be.” And even though it’s not easy to take feedback from our romantic partners, she was right and so obviously so, that I had no argument” which led me to tell her, “I’m not going to yell at our daughter any more. I am, instead going to whisper, because I learned in a parenting book, that sometimes when you’re angry it’s more effective to whisper than it is to yell. That was my new plan. Of course, like new plans everywhere, it needed tweaking. But it didn’t take long for me to have an opportunity to test it because if there’s anything on the planet that’s predictable, it’s that we’ll all soon have another chance to manage our anger toward our children more constructively.

It was the next day or week and my daughter did not get her boots on and she was not on the same schedule as me and I got down in her face, once again, but I remembered the plan to whisper and I did my best to transform my anger from the historical yell to the contemporary whisper and what happened was that what came out was sort of like the exorcist and I said to my daughter: “GET YOUR BOOTS ON!”

Now. I wasn’t especially proud of that, but she got her boots on.

It was the beginning of a big change for me because I learned I could play the exorcist instead of yelling; then I learned to growl and then I learned to count to three and then I learned a cool technique called Grandma’s rule where you use the formula, WHEN YOU, THEN YOU to set a limit and build in a positive outcome. Like . . . “Honey, when you get your boots on, then you can have your cell phone back.” Very cool.

What I learned from this experience is that I could be more than a one-trick parenting pony. I became the kind of parent who, although far from perfect, was able to set limits that were in my daughter’s best interest.

And what I like the best about this particular story is that daughter is now 26 years-old and she still says the same thing she used to say to me when she was 15 . . . that is, “Dad, one thing I really love about you is you never yell.” What’s cool is that I did yell, but I worked on it, I made a new plan, and now she doesn’t even remember the yelling.

I’d like to finish with one last story about how much parents need people like you to have empathy, collaborate, validate, and offer concrete parenting ideas.

I was working with a 15-year-old boy. His mom was bringing him to counseling because he and his dad weren’t speaking anymore. I hadn’t met the dad, but one day, when I went to the boy’s IEP meeting at school the dad was there. I saw this as a chance to make a connection and get him to come to counseling.

I did a little chit-chatting and sat next to him in the group meeting. Then, at one point, I asked the boy a question: “If you got an A on a test, who would you show first?” He answered, “I’d show my dad, my mom, and my special ed teacher.” This inspired me to turn to his dad and say, “It’s obvious that you’re very important to your son and so I’d like to invite you to come join him and me in counseling.” Dad gave me a glare and pushed my shoulder and began a 2-minute rant about how the school had failed his son. Everyone was stunned and then he turned back to me and said, “I’ll come to counseling. I been to counseling before and I can do it again.”

At that point I wondered if I could take back my offer.

The day the dad drove to counseling he and his son weren’t speaking, so I met with them separately. The son was clear that he would never speak to the dad again, but the dad was open. When I asked if I could offer him some ideas, he said, “Well I tried MY best and that dog don’t hunt, so I can try something else.” I was wishing for subtitles.

I told the dad I wanted him to keep his high standards for his son, but to add three things. First, I asked, do you love your son? The dad said “Yes” and so I told him, “Okay then. I want you to tell him ‘I love you’ every day.” He said, “Usually I leave that to the wife, but I can do that.” Second, I said, “Everyday, I want you to touch your son in a kind and loving way.” He asked, “You mean like give him a hug?” I said, “that would be great” and he responded, “Usually I leave that to the wife too, but I’ll give it a shot.” Third, I said, “Once a week, you should do something fun with your son, but it has to be something that he thinks is fun.” He said back: “That’s no problem. We both like to go four-wheeling, so we’ll do that.”

And they left my office for an hour-long of what I imagine was a silent trip home.

The next afternoon, I got a call from the mom. She was ecstatic. She said, “I don’t know what you did or what you said, but they’re talking again.” And then she added, “This morning, when they were in the kitchen, I was in the other room and I thought I heard them hug and when I saw my son walking down the driveway to head to school, there were tears running down his cheeks.”
This was obviously a mom who was listening and watching very closely.

Things got much better for the 15-year-old after that. He didn’t get straight As, but he stopped getting straight Fs. And I learned two things: First, I learned just how much that boy needed to get reconnected with his father. And second, I learned that sometimes, no matter how gruff parents may seem, what they need is some clear and straightforward advice about how to reconnect with their son or daughter.

My final thoughts about this topic are very simple. I hope you’re inspired enough to acquire the knowledge and skills it takes to work effectively with parents. I know their children will deeply appreciate it.

Thanks for listening.

John and Nora

 
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Posted by on February 15, 2015 in Parenting

 

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Upcoming Workshops on Love and Couple Counseling at the University of Montana

Upcoming Workshops on Love and Couple Counseling at the University of Montana

Starting on February 27, 2015, the Department of Counselor Education at the University of Montana will be offering a “LOVE” Workshop Series on campus in Missoula. This workshop series will include four different full-day trainings. The dates, topics and presenters for this series is below . . . and a registration form is attached. Registration form LOVE – Final

Session I: Friday, February 27, 2015, 8:30-4:30
Part One: Facilitating Intimate Conversations
Presented by: Veronica Johnson, Ed.D. and Kirsten Murray, Ph.D. – University of Montana

In American culture, romantic partners are taught to dread having serious relationship talks. This workshop focuses on helping couples build positive expectations and effective skills for communicating directly about their relationship and relationship issues like sex, money, and in-laws.

Part Two: The Business of Working with Couples
Presented by: Jana Staton, Ph.D. – Independent Practice – Marriage Works

Although helping couples have happier and healthier relationships is intrinsically rewarding, if you’re a professional counselor or therapist, you probably want to get paid too. In this workshop, Jana Staton, Ph.D. will offer tips for maximizing the efficiency of the business side of your couples counseling practice.

Session II: Friday, March 20, 2015, 8:30-4:30
Romantic Relationships as Healthy Partnerships:
Adlerian Approaches to Couple Counseling and Education
Presented by: Jon Carlson, Psy.D., Ed.D. – Governor’s State University

In this workshop, Jon Carlson, Psy.D., Ed.D., author of 60 books and producer of over 300 counseling and psychotherapy training videos, will provide training on the Adlerian approach to couple counseling. His presentation will include two main parts: (a) a discussion of the relationship enhancement activities of TIME (Training in Marriage Enrichment), and (b) a focus on the principles and practices of Adlerian couple counseling (including a live case demonstration!).

Session III: Friday, April 24, 2015, 8:30-4:30
Emotion-Focused Couple Counseling
Presented by: Mark Young, Ph.D., Gonzaga University

Based on a foundation of attachment theory, emotion-focused couples therapy is currently one of the most popular and scientifically-supported approaches to working effectively with romantic couples. In this workshop, Mark Young, Ph.D., will help you understand the theoretical foundations and learn practical skills necessary to using emotion-focused couples therapy in your practice.

Session IV: Friday, May 8, 2015, 8:30-4:30
Part One: Complications of Love: The Challenge of Parenting
Presented by: Sara Polanchek, Ed.D. and John Sommers-Flanagan, Ph.D.

Researchers consistently report that romantic relationship satisfaction decreases with the birth of the first child and continues to decrease for about the next 20 years. The focus of this workshop will be on how parents can parent as partners and sustain their love and romance through the childrearing years.

Part Two: Complications of Love: Aging Well Together
Presented by: Catherine Jenni, Ph.D. and Jana Staton, Ph.D.

Recent research has surprising scientific findings from neuroscience, health outcome studies, and clinical trials about the effects of interactions with those we love on our immune, cardiovascular, and nervous systems. This workshop will include tips and best practices on how to keep a couple relationship alive, even in the face of declining health, aging, or illness.

 
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Posted by on February 7, 2015 in Couple Counseling, Love

 

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Wishing for a Super Bowl that Promotes Non-Violence

It’s been a tough year for the National Football League. There was renewed emphasis (for a while) on the devastating brain damage caused by repeated concussions. Then there was the Ray Rice domestic violence incident. And then there was the Adrian Peterson child abuse incident. And now there’s the Aaron Hernandez trial for murder and weapons charges that started a couple days ago. All these scandals added up to big, bad publicity . . . so much so that the Fiscal Times noted in a recent headline that these incidents “Rocked the NFL.”

Then there was deflate-gate, the ridiculousness that led us to wonder if our football heroes might just be a bunch of cheats.

But wait.

Through all these scandals the NFL has continued laughing its way to the Bank with obscene gobs of money that could be used to wipe out Ebola or end child abuse. Last year, NFL commissioner Roger Goodell made about $44 million. Vegas odds are that he’ll do better this year. Super Bowl advertisings are doing just fine, thank-you. And Katy Perry may or may not have a wardrobe malfunction tomorrow evening, but you can bet there will be millions of viewers. The NFL is right on pace to increase its economic worth to something well over being a $9 billion dollar industry. Not bad. Talk about Teflon.

It’s clear the situation is hopeless and that the Juggernaut that is the NFL will stroll into the future without substantially addressing anything that might be remotely linked to a social virtue. Nevertheless, I can’t stop cheering for underdogs, and that leaves me with an array of dreams that are so silly that I’m embarrassed to admit them. That said, I’ll go ahead and embrace my embarrassment and tell you what I’m watching for tomorrow.

I’ll be watching to see how many advertising bucks are used to promote domestic violence or child abuse prevention. Will we see NFL players, coaches, owners, and the commissioner go on record to support sexual assault prevention? Might there be room for the tiniest of sprinklings of valuable educational public service announcements during the four hour Super Bowl feast?

I think not; but I hold out hope.

And here’s my biggest irrational wish. I’m wishing for the NFL to provide educational information about the dangers of corporal punishment. Adrian Peterson said something to the effect that all he did was send his kiddo out to get a stick so he could beat him with it, just like his Momma did to him. Peterson was talking about our great American tradition of believing that it’s a good thing for parents to hit their children.

Even more disturbing than the single Adrian Peterson incident is the fact that during a typical 4 hour time period (about the length of the Super Bowl broadcast) there are approximately 1,500 reports of child abuse . . . and so maybe, just maybe, we could use a little NFL-sponsored education here.

But what really smacks my pigskin is the fact that Adrian Peterson’s parenting philosophy is still alive and well on the internet. In particular, it’s featured on the website of Christian “parenting expert” James Dobson. Seriously. It’s on a Christian-based website. This is stunning not only because there’s a truckload of science telling us that hitting kids is linked to bad outcomes, but also because it’s pretty difficult to imagine the Jesus that I read about in the Bible hitting children with a stick . . . or advocating the hitting of children with a stick.

Now that it’s the 21st century and time for Super Bowl XLIX, shouldn’t we know better? Shouldn’t we know that we shouldn’t send our kids out to get sticks so we can beat them? Come on NFL . . . just share that fun fact. Just come out and say you don’t support beating children . . . and how about you take 0.001% of your net worth and use it to launch an educational campaign that will teach parents what to do instead of hitting kids.

That’s what I’ll be watching for tomorrow . . . if I can manage to stomach turning on the game at all.

 

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Resistance Busters: How to Work Effectively with Teens who Resist Counseling

Young clients or students and their parents will sometimes be immediately resistant to your efforts to help them change. I don’t mean this in the old-fashioned psychoanalytic form of resistance that blames clients. I mean this as a natural resistance to change. I think we’ve all felt it. Someone has some helpful advice and we feel immediately disinclined to listen and even less inclined to follow the advice. I remember this happening with my father—even when he wanted to tell me something about sports. Of course, he knew a TON more about sports than I did, but logic was not the issue. When it comes to relationships and influencing people, logic is rarely relevant.

If we can buy into using the word resistance—despite the fact that Steve de Shazer buried it in his backyard and had a funeral for it, we would be likely to conclude that resistance behaviors are especially prominent among youth who view their presence in therapy as involuntary. Think of school, court, or parent referred children. Below, in an effort to capture what happens in these situations, Rita and I came up with what we call common resistance styles. Again, the point is not to blame clients or students; after all, they usually come into counseling or therapy with a history that makes their resistance totally natural. Besides, why should we expect them to pop into a therapist’s office and suddenly experience trust and share their deepest feelings.
In combination with these so-called resistance styles, we’ve also developed a range of possible therapeutic responses. To be with de Shazer’s (1985) solution-focused model and because they constitute a first best guess regarding how to respond to these particular resistance styles, we refer to these responses as “formula responses.” Keep in mind that if one formula response is ineffective, an alternative one may be used to reduce and manage this pesky resistance-like behavior.

Resistance Style: Externalizer/Blamer
This young person quickly blames everyone and everything for his or her problems. S/he may feel persecuted; there also may be evidence supporting his/her persecutory thoughts and feelings. Alternatively, the youth may simply have trouble accepting personal responsibility.

SAMPLE STATEMENT: “I would never have flunked science if it weren’t for my teacher. He sucks big-time.”

Formula Responses: One key to responding to this youth is to blatantly side with his or her affect. In the early stages, confrontation with this type of youth is generally ill-advised. For example, Bernstein (1996) states: “Despite a lack of evidence to back up their arguments, we listen carefully without passing judgment” (p. 45). The blamer is sometimes so hypersensitive to criticism that he sees it coming a mile away. Therefore, especially at the outset of therapy, therapists should be cautious about providing criticism or negative feedback. As the client blames others be sure to grunt and moan and say things like, “Oh yeah, I hate it when teachers aren’t fair.” or just use standard person-centered reflections, “You’re saying that being around your teacher really sucks . . .it feels real bad.”

Resistance Style: The Silent Youth
This youth may refuse to speak or may boldly claim that she doesn’t have to talk to you. This youth may have strong needs for power and control and/or may be afraid of what she might say during counseling.

SAMPLE STATEMENT: “I don’t have to talk to you. And you can’t make me.”

Formula Responses: For the completely silent youth who appears to be stonewalling, it may be useful to use a combination of youth-centered reflection of feeling/content and self-disclosure or forced teaming. For example, you might say: “Seems like you really don’t want to be here and you also really don’t want me to know anything about you.” And/or: “If I were you, I wouldn’t trust me either. After all, you were sent here by people you don’t trust and so you probably think I’m on their side. I’d like to prove I’m not on their side, but the only way we can really shock your parents (or probation officer) is by you talking with me and then you and I teaming up to help you have more control over your life.” In the case where the client boldly claims that she does not have to talk with you, it can be helpful to strongly agree with the youth’s assertion (and then simply inquire as to what has been happening in the youth’s life.: “You are absolutely right. You ARE totally in control over whether you talk with me and how much you talk with me.” Then, after a short pause say, “Now, what do you want to talk about?” Sometimes acknowledging the youth’s power and control can decrease his/her need for it.

Resistance Style: The Denier
This is the youth who Repeatedly says: “I’m fine” or “I don’t know” when neither statement is likely to be the truth. These youths can be especially frustrating to therapists because whatever life circumstances that led the youth to therapy are clearly difficult and progress might be made if the youth would admit to having problems. Unfortunately, these youths may have such fragile self-esteem that admitting that any problems are occurring in their lives is very threatening.

SAMPLE STATEMENT: “I’m fine, I don’t have any problems.”

Formula Responses: With youth who say, “I’m fine” we suggest one of two possible formula responses. First, you might say: “If you’re fine, then somebody in your life must not be fine, otherwise, you wouldn’t be here. So, tell me about who forced you to come and what his or her problems are?” The purpose of this statement is to get youths to at least become “blamers” so that you can side with the affect and start building rapport. Second, Bernstein (1996) suggests a statement similar to the following: “You may be right and you may be fine, but if you don’t talk with me about your life, I’ll never know whether you’re fine or not.” Suggested formula responses to “I don’t know” include: “Okay, then tell me something you do know about this problem” or “Tell me what you might say if you did know” or “Boy, it sounds like there are lots of things about your life that you don’t know anything about. We’d better get to work on figuring this stuff out” or John’s favorite, which is: “Take a guess.”

Resistance Style: The Nonverbal Provocateur
Some young clients are so good at irritating other people with their nonverbal behavior that they deserve an award. These youth are often keeping adults at a distance because they don’t trust that the adults will understand or appreciate their adolescent dilemmas. These youths also are notorious for being able to “piss off” their parents, teachers, probation officers, and therapists. They may do so through eye-rolls, sneers, lack of eye contact, or other irritating nonverbal behaviors. Analytic theorists believe this is because they have such profound self- hatred that they unconsciously believe they deserve to be treated poorly by others, especially adults (Willock, 1986, 1987).

SAMPLE STATEMENT: “Yeah, right. Duh” (while youth’s eyes roll back and she heaves a significant sigh).

Formula Responses: When faced with the nonverbal provocateur, we recommend using the strategy we have referred to elsewhere as “interpersonal interpretation” (See Tough Kids, Cool Counseling). This strategy includes several steps. First, the therapist allows the youth to make whatever disrespectful nonverbal behaviors she wants to, without acknowledgment. Second, after a substantial number of eye-rolls, etc., have occurred, the therapist makes a statement such as: “Are people treating you okay.” This statement is designed to provoke complaints from the youth about whomever has been treating her so poorly. Third, the therapist discloses his or her reactions to the nonverbal behaviors: “The reason I bring this up is because, for a moment, significant sigh).I felt like being mean to you.” Fourth, the therapist suggests that the youth may already realize why the therapist “felt like being mean” to the youth or discloses that these feeling arose in response to the youth’s nonverbal behaviors. Fifth, the therapist suggests that the reason other people are treating the youth poorly is related to eye-rolls, etc., outside of therapy. Sixth, the therapist inquires as to whether the youth has control over his/her irritating nonverbal behaviors. Seventh, the therapist encourages the youth to conduct an experiment to see how people treat him/her one day when using lots of eye-rolls and another day while not using eye-rolls.

Resistance Style: The Absent Youth
There are at least two types of absent youths. First, there are young people who arrive with their parent or parents, but who refuse to leave the waiting room. Second, there are young clients who, after an initial appointment, keep missing their subsequent appointments.
In either case, resistance is high. These youth may be even more afraid of therapy and losing power the control than other youth, who at least make it into the counseling office.

SAMPLE STATEMENT: “I’m not going back and you can’t make me.”

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Formula Responses: It’s essential that young clients or students not be “dragged” into the therapy office. Therefore, the youth is simply informed that the session(s) will proceed without the youth present but that the session will still be “about” the youth. Subsequently, the session focuses on parent education and family dynamics. During this session, therapist should offer and serve food and drink to the participating family members. Also, partway through the session (if the young client is in the waiting room) one family member may ask once more if the youth would like to join them in the meeting. However, this request should only occur once and it should not involve any pleading. For young clients who miss their appointments, an invitation letter as suggested by White and Epston may be useful or, if you’re more behaviorally inclined, a contingency program may be designed to provide the youth with appropriate reinforcers and consequences.

Resistance Style: The Attacker
Similar to Matt Damon in the film Good Will Hunting, some youth will try to provoke the therapist by attacking whatever therapist personal traits that he or she can identify. It may be office decor, personal items (e.g., family pictures), clothing, the office itself, the voice tone, body posture, attractiveness, etc. The attacker’s ploy is often clear from the outset: The best defense (aka: resistance) is a good offense.

SAMPLE STATEMENT: “I noticed that everyone else here has a bigger office than you. You have a shitty little office; you must be a shitty little therapist.”

Formula Responses: We believe that two rules are crucial with young clients who consistently verbally attack the therapist. First, unlike Robin William’s character in the popular movie, you should not attempt to “choke” the youth (even therapist’s though you may feel like choking the client). In other words, therapists should not respond defensively or offensively to attacks by the youth. Second, the therapist may interpret the youth’s behavior by clearly demonstrating that the comments, whether true or not, say much more about the youth than they say about the therapist. After a few interpretations of the youth’s underlying psychodynamics, the youth usually will cease and desist with the attacks because he or she sees that every attack comes back to him or her in the form of an interpretation.

Resistance Style: The Apathetic Youth
The apathetic youth is similar to the denier, except that the formidable strategy of simply not caring about anyone or anything is the primary defense. This defense often arises out of depressive or substance related emotional and behavioral problems

SAMPLE STATEMENT: “Trust me, I really don’t give a shit about anything you’re saying!”

Formula Responses: Hanna and Hunt (1999) recommended using a sub-personality or ego state approach to dealing with adolescent apathy. This approach involves three steps: (a) take great care to empathize with the youth’s apathy; this might involve saying things like, “Okay, okay, I get it, you really don’t give a shit.”; (b) after empathizing, use a question like, “I know you don’t care, but isn’t there a little part of you, maybe a voice in the back of your head or something, that worries, maybe only a tiny bit about what might happen to you?”; (c) focus on the part of the youth that acknowledges caring about what happens and eventually begin labeling the “caring” part of the adolescent as the “real” self, while reducing the apathetic part of the self to the “fake” self.

More information about how to work through resistance is in our Tough Kids, Cool Counseling book, which happens to have five 5-star ratings on Amazon. Check it out:

 

 

 

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Suicide Risk Factors, Part III

It’s been awhile since I started my holiday and post-holiday look at suicide risk factors. In previous posts I focused on Demographic and Ethnic Factors related to death by suicide and then on the broad category of Mental Disorders and Psychiatric Treatment. This post focuses on Personal and Social Factors that are linked to suicide.

Not to worry, soon I’ll be moving beyond this tragic but important topic.

The following is mostly an excerpt from our Clinical Interviewing text.

Social and Personal Factors

There are a number of social and personal factors linked to increased suicide risk. Many of these factors have been reviewed and integrated into Thomas Joiner’s interpersonal theory of suicide (Joiner & Silva, 2012; Van Orden et al., 2010).

Social Isolation/Loneliness
In a review of the literature, 34 research studies were identified that include support for social isolation as a suicide risk factor (Van Orden et al., 2010). These findings provide support for Joiner’s (Joiner & Silva, 2012) attachment-informed interpersonal theory of suicide. Van Orden et al (2008) described the two primary dimensions of Joiner’s interpersonal theory:

The theory proposes that the needs to belong and to contribute to the welfare of close others are so fundamental that the thwarting of these needs (i.e., thwarted belongingness and perceived burdensomeness) is a proximal cause of suicidal desire. (Van Orden et al., 2008, p. 72)

Interpersonal theory explains why a number of social factors, such as unemployment, social isolation, reduced productivity, and physical incapacitation are associated with increased suicide risk. Specifically, research indicates that divorced, widowed, and separated people are in a higher suicide-risk category and that single, never-married individuals have a suicide rate nearly double the rate of married individuals (Van Orden et al., 2010). Based on interpersonal theory, an underlying reason that these factors are linked to suicidality is because they involve thwarted belongingness and a self-perception of being a burden to family and friends, rather than contributing in a positive way to the lives of others.

In a fairly recent study, the suicide notes of 98 active duty U.S. Air Force (USAF) members were analyzed. Using Joiner’s interpersonal theory, results indicated strong themes of hopelessness, perceived burdensomeness, and thwarted belongingness. Overall, interpersonal risk factors were communicated more often than intrapsychic risk factors. (Cox et al., 2011).

Physical Illness

Many decades of research have established the link between physical illness and suicide. Specific illnesses that confer suicide risk include brain cancer, chronic pain, stroke, rheumatoid arthritis, hemodialysis, and HIV-AIDS (e.g., (Lin, Wu, & Lee, 2009; Martiny, de Oliveira e Silva, Neto, & Nardi, 2011). Overall, although physical illness is a major predictor, several social factors appear to mediate the relationship between illness and death by suicide. In particular, Joiner’s concept of becoming a social burden seems a likely contributor to suicidal behavior, regardless of specific diagnosis (Van Orden et al., 2010). Similar to previously hospitalized psychiatric patients, medical patients also exhibit higher suicidal behavior shortly after hospital discharge (McKenzie & Wurr, 2001).

Previous Attempts

Over 27 separate studies have indicated that suicide risk is higher for people who have previously attempted (Beghi & Rosenbaum, 2010). Van Orden et al. (2010) refer to previous attempts as “. . . one of the most reliable and potent predictors of future suicidal ideation, attempts, and death by suicide across the lifespan” (p. 577).

As one example, in a 15-year prospective British study of deliberate self-harm, repeated self-harm was a strong predictor of eventual suicide, especially in young women (Zahl & Hawton, 2004). By the study’s end, 4.7% of women who had repeatedly engaged in deliberate self-harm committed suicide as compared to 1.9% in the single episode group. In this study, deliberate self-harm was defined as intentionally poisoning or self-injuring that resulted in a hospital visit. The study concluded that repeated deliberate self-harm increases suicide risk in males and females, but is a particularly salient predictor in young females. This is the case despite the fact that some clients use cutting, burning, or other forms of self-harm to aid in emotional regulation. Overall the research suggests that self-harm that rises to the level of hospitalization is likely beyond that which enhances self-regulation and instead constitutes practicing or successive approximation toward suicide.

Unemployment

Individuals who have suffered any form of recent, significant personal loss should be considered higher suicide risk (Hall, Platt, & Hall, 1999). However, in particular, unemployment is a life situation that repeatedly has been linked to suicide attempts and death by suicide. Joiner’s (2005) interpersonal theory of suicide posits that unemployment confers suicide risk at least partly because of individuals experiencing an increased sense of themselves as a burden on others. Other losses that can increase risk include (a) status loss, (b) loss of a loved one, (c) loss of physical health or mobility, (d) loss of a pet loss, and (e) loss of face through recent shameful events (Beghi & Rosenbaum, 2010; Packman, Marlitt, Bongar, & Pennuto, 2004).

Sexual Orientation

Over the years the data have been mixed regarding whether gay, lesbian, bisexual, or transgender individuals constitute a high suicide risk group. More recently, a 2011 publication in the Journal of Homosexuality reported there is no clear and convincing evidence that GLBT individuals die by suicide at a rate greater than the general population (Haas et al., 2011).
Although this is good news, the data also show that GLB populations have significantly higher suicide attempt rates. Haas et al (2011) wrote:

Since the early 1990s, population-based surveys of U.S. adolescents that have included questions about sexual orientation have consistently found rates of reported suicide attempts to be two to seven times higher in high school students who identify as LGB, compared to those who describe themselves as heterosexual. (p. 17)

Overall, it’s likely that transgender people and youth questioning their sexuality may be at increased risk for suicide attempts or death by suicide. Additionally, GLBT youth who have experienced homosexual-related verbal abuse and parental rejection for their behaviors related to gender and sexuality are more likely to engage in suicidal behaviors (D’augelli et al., 2005).

In conclusion, as you can probably see from this and the two previous posts, there are many complex and potentially interacting factors associated with increased suicide risk, but no great predictors. This is unfortunate for those of us who would like to use prediction methods to prevent and reduce suicide rates. But, at the same time, the fact that many people who experience great suffering in their lives still choose life, is a testament to human strength and resiliency.

And, speaking of resiliency, maybe I’ll be focusing on an exciting and upbeat topic like that next time. Until then, I wish you all the best in your efforts to help your clients through difficult times in their lives. Your work may be more important than you think.

 

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Suicide Risk Factors: Part II

There are many ways to think about suicide risk factors. In my last post, I focused on demographic and ethnic factors related to death by suicide. In this post, the focus is on the broad category of Mental Disorders and Psychiatric Treatment. The next post will focus on Personal and Social Factors that are linked to suicide.

As you’ll see below, the relationship between mental disorders, psychiatric treatment, and suicide is complex. The following material is adapted from our textbook, Clinical Interviewing and so you can find more information there: http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=asap_B0030LK6NM?ie=UTF8

Mental Disorders and Psychiatric Treatment

In general, psychiatric diagnosis is considered a risk factor for suicide. However, some diagnostic conditions (e.g., bipolar disorder and schizophrenia) have higher suicide rates than others (e.g., specific phobias and oppositional-defiant disorder). Several diagnostic conditions associated with heightened suicide risk are discussed in this section.

Schizophrenia

Schizophrenia is a good example of a mental disorder that has a complex association with increased suicide risk. As you may realize, many individuals diagnosed with schizophrenia are unlikely to attempt suicide or die by suicide. Some individuals with a schizophrenia diagnosis are at higher suicide risk than others.

In 2010, Hor and Taylor conducted a research review of risk factors associated with suicide among individuals with a diagnosis of schizophrenia. They initially identified 1,281 studies, eventually narrowing their focus to 51 with relevant schizophrenia-suicide data. Overall, they reported a lifetime suicide risk of about 5% (Hor & Taylor, 2010). Given that the annual risk in the general population is about 12 in 100,000 and assuming a life expectancy of 70 years the general lifetime risk is likely about 840 in 100,000 or 0.84%. This suggests that suicide risk among individuals diagnosed with schizophrenia is about 6 times greater than suicide risk within the general population.

However, there are unique predictive factors within the general population of individuals diagnosed with schizophrenia that further refine and increase suicide prediction. Hor and Taylor (2010) reported the following more specific suicide risk factors within the general population of individuals with a schizophrenia diagnosis:

  • Age (being younger)
  • Sex (being male)
  • Higher education level
  • Number of prior suicide attempts
  • Depressive symptoms
  • Active hallucinations and delusions
  • Presence of insight into one’s problems
  • Family history of suicide
  • Comorbid substance misuse (p. 81)

If you’re working with a client diagnosed with schizophrenia, the lifetime suicide prevalence for that client is predicted to be higher than in the general population. Presence of any of the preceding factors further increases that risk. This leaves a “highest risk prototype” among clients with schizophrenia as:

A young, male, with higher educational achievement, insight into his problems/diagnosis, a family history of suicide, previous attempts, active hallucinations and delusions, along with depressive symptoms and substance misuse.

Given what’s known about suicide unpredictability, it’s also important to remember that someone who fits the highest risk prototype may not be suicidal, whereas a client with no additional risk factors may be actively suicidal.

Depression

The relationship between depression and suicidal behavior is very well established (Bolton, Pagura, Enns, Grant, & Sareen, 2010; Holikatti & Grover, 2010; Schneider, 2012). Some experts believe depression is always associated with suicide (Westefeld and Furr, 1987). This close association has led to the labeling of depression as a lethal disease (Coppen, 1994).

It’s also clear that not all people with depressive symptoms are suicidal. In fact, it appears that depression by itself is much less of a suicide predictor than depression combined with another disturbing condition or conditions. For example, when depression is comorbid (occurring simultaneously) with anxiety, substance use, post-traumatic stress disorder, and borderline or dependent personality disorder, risk substantially increases. (Bolton et al., 2010). Earlier research also supports this pattern, with suicidality increasing along with additional distressing symptoms or experiences, including:

  • Severe anxiety
  • Panic attacks
  • Severe anhedonia
  • Alcohol abuse
  • Substantially decreased ability to concentrate
  • Global insomnia
  • Repeated deliberate self-harm
  • History of physical/sexual abuse
  • Employment problems
  • Relationship loss
  • Hopelessness (Fawcett, Clark, & Busch, 1993; Marangell et al., 2006; Oquendo et al., 2007)

Given this pattern it seems reasonable to conclude that when clients are experiencing greater depression severity and/or additional distressing symptoms, suicide risk increases. Van Orden and colleagues offered a similar conclusion:

. . . data indicate that depression is likely associated with the development of desire for suicide, whereas other disorders, marked by agitation or impulse control deficits, are associated with increased likelihood of acting on suicidal thoughts. (Van Orden et al., 2010, p. 577)

Bipolar Disorder

Research has repeatedly shown that individuals diagnosed with bipolar disorder at increased risk of suicide. Similar to schizophrenia and depression, there are many specific risk factors that predict increased suicidality among clients with bipolar disorder.

In a large-scale French study, eight risk factors were linked to lifetime suicide attempts (Azorin et al., 2009). These included:

1. Multiple hospitalizations
2. Depressive or mixed polarity of first episode
3. Presence of stressful life events before illness onset
4. Younger age at onset
5. No symptom-free intervals between episodes
6. Female sex
7. Greater number of previous episodes
8. Cyclothymic temperament (p. 115)

These findings are consistent with the research on unipolar depression; it appears that severity of bipolar disorder and accumulation of additional distressing experiences increase suicide risk. Another study identified (a) White race, (b) family suicide history, (c) history of cocaine abuse, and (d) history of benzodiazepine abuse were associated with increased suicide attempts (Cassidy, 2011)

Post-Traumatic Stress

In 2006, renowned psychologist Donald Meichenbaum reflected on his 35-plus years of working with suicidal clients. He wrote:

In reviewing my clinical notes from these several suicidal patients and the consultations that I have conducted over the course of my years of clinical work, the one thing that they all had in common was a history of victimization, including combat exposure (my first clinical case), sexual abuse, and surviving the Holocaust. (Meichenbaum, 2006, p. 334)

Clinical research supports Meichenbaum’s reflections. For example, in a file review of 200 outpatients, child sexual abuse was a better predictor of suicidality than depression (Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). Similarly, data from the National Comorbidity Survey (N = 5,877) showed that women who were sexually abused as children were 2 to 4 times more likely to attempt suicide, and men sexually abused as children were 4 to 11 times more likely to attempt suicide (Molnar, Berkman, & Buka, 2001). Overall, research over the past two decades points to several stress-related experiences as linked to suicide attempts and death by suicide (Wilcox & Fawcett, 2012). These include general trauma, stressful life events, and childhood abuse and neglect. Characteristics of these experiences that are most predictive of suicide are:

  • Assaultive abuse or trauma.
  • Chronicity of stress or trauma.
  • Severity of stress or trauma.
  • Earlier developmental stress or trauma. (Wilcox & Fawcett, 2012)

These particular life experiences appear related to suicidal behavior across a variety of populations—including military personnel, street youth, and female victims of sexual assault (Black, Gallaway, Bell, & Ritchie, 2011; Cox et al., 2011; Hadland et al., 2012; Snarr et al., 2010; Spokas, Wenzel, Stirman, Brown, & Beck, 2009).

Substance Abuse

Research is unequivocal in linking alcohol and drug use to increased suicide risk (Sher, 2006). Suicide risk increases even more substantially when substance abuse is associated with depression, social isolation, and other suicide risk factors.

One way that alcohol and drug use increases suicide risk is by decreasing inhibition. People act more impulsively when in chemically altered states and suicide is usually considered an impulsive act. No matter how much planning has preceded a suicide act, at the moment the pills are taken, the trigger is pulled, or the wrist is slit, some theorists believe that some form of disinhibition or dissociation has probably occurred (Shneidman, 1996). Mixing alcohol and prescription medications can further elevate suicide risk.

Several other specific mental disorders have clear links to death by suicide. These include:

  • Anorexia nervosa
  • Borderline personality disorder
  • Conduct disorder (see Van Orden et al., 2010)

Post-Hospital Discharge

For individuals admitted to hospitals because of a mental disorder, the period immediately following discharge carries increased suicide risk. This is particularly true of individuals who have additional risk factors such as previous suicide attempts, lack of social support, and chronic psychiatric disorders. Overall, suicide ideation and attempts are predictably high. In one study 3.3% completed suicide within 6 months of discharge, whereas 39.4% had self-harm behaviors or suicide attempts (Links et al., 2012). Another study reported “3% of patients categorized as being at high risk can be expected to commit suicide in the year after discharge” (Large, Sharma, Cannon, Ryan, & Nielssen, 2011, p. 619).

Selective Serotonin Reuptake Inhibitors (SSRIs)

Over the past two decades, empirical data linking SSRI medications to suicidal impulses has accumulated to the point that recent administration of SSRI medications should be considered a possible suicide risk factor (Breggin, 2010; Valenstein et al., 2012). This is true despite the fact that some research also shows that SSRI antidepressants reduce suicide rates (Kuba et al., 2011; Leon et al., 2011). Overall, it appears that in a minority of clients (2–5%) SSRI antidepressants may increase agitation in a way that contributes to increased risk for suicidal behaviors (J. Sommers-Flanagan & Campbell, 2009).

In September 2004, an expert panel of the U.S. Food and Drug Administration (FDA) voted 25–0 in support of an SSRI-suicide link. Later, the panel voted 15–8 in favor of a “black box warning” on SSRI medication labels. The warning states:

Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of Major Depressive Disorder (MDD) and other psychiatric disorders. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.

In 2006, the FDA extended its SSRI suicidality warning to adult patients aged 18–24 years (United States Food and Drug Administration, 2007).

There’s no doubt that debate about whether SSRI medications increase suicide risk will continue. In the meantime, prudent practice dictates that mental health providers be alert to the possibility of increased suicide risk among clients who have recently been prescribed antidepressant medications (Sommers-Flanagan & Campbell, 2009).

In the next post in this series I’ll be focusing on Personal and Social factors associated with suicide.

 

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