For the revision of our Counseling and Psychotherapy text, Rita and I are contemplating how to integrate some neuroscience information in a balanced way. Each chapter would include a short section discussing neuroscience as it pertains to each theoretical perspective. This essay is one effort for beginning or framing the discussion. Check it out (if you like this sort of thing) and let me know your thoughts (if you do that sort of thing).
From Biological Psychiatry to Interpersonal Neurobiology
In 1980, I (John) began my career in mental health services as a recreation therapist in a 22-bed psychiatric hospital. The patients were experiencing severe depression, manic episodes, and psychotic symptoms.
There was a large and intimidating psychiatrist (Dr. M) on the unit. Dr. M was a fan of biological psychiatry. He would smile as I engaged patients in the “Newly-Friend Game” (like the Newly-Wed Game, only better), relaxation groups, bowling nights, and ice cream socials. Occasionally Dr. M cornered me, explaining how my “cute” recreational programs had absolutely no influence on our hospitalized patients’ mental health. He waxed eloquent about brain chemistry. Never mind that the Thorazine and Haldol he prescribed had nasty side effects. Eventually, he claimed, there would be designer drugs that cured mental disorders from the inside out. Everything else was irrelevant.
I had a fresh, new bachelor’s degree in psychology. Dr. M had his M.D. He knew more than I did. Class dismissed. But it’s funny how encountering a condescending attitude can be motivating. I figured there must be a brain chemistry explanation for that too.
The chemical imbalance theory of mental disorders continued its dominance through the 1980s and 90s. Explanations for psychopathology focused on too much dopamine (causing schizophrenia) and not enough norepinephrine or serotonin (causing depression). No one really knew what caused these so-called imbalances, but biogenetic factors were the prime suspects. Although I kept silent with Dr. M, I held tight to my beliefs that social, psychological, and physical experience could be therapeutic.
Evidence slowly rolled in. While teaching a class on developmental counseling, I found a study showing that testosterone levels vary as a function of winning or losing tennis matches (Booth, Shelley, Mazur, Tharp, & Kittok, 1989). My brain (and the chemicals therein) loved this idea. If our testosterone levels could change based on competitive experiences, what other ways might human behavior influence the brain?
In 1998, while perusing research on serotonin and depression, I discovered that treadmill running increased brain serotonin in rats. The researcher described the complexity of the phenomenon:
Lipolysis-elicited release of free fatty acids displaces the binding of tryptophan to albumin and because exercise increases the ratio of circulating free tryptophan to the sum of the concentrations of the amino acids that compete with tryptophan for uptake at the blood-brain barrier level, tryptophan enters markedly in the brain compartment. (Chaoeloff, 1997, p. 58)
But my take-home message was simple: physical exercise might increase serotonin in human brains and also help alleviate depression.
Then neurogenesis came along. Neurogenesis is the creation of new brain cells. It has been long known that during fetal development, cells are created and migrate to specific places in the brain and body where they engage in their specific role and function. Cells that become rods and cones end up in the eyes, while other cells become bone, and still others end up in the cerebral cortex. In the 1980s and 1990s, everyone agreed that that neurogenesis continued during infancy, but most neuroscientists also believed that after early childhood the brain locked down and neurogenesis stopped. In other words, as adults, we only had neuronal pruning (cell death) in our future.
In the late 1980s, neuroscientists began conducting research that shook long-held assumptions about neurogenesis. For example, Jenkins and colleagues housed adult monkeys in cages where the monkeys had to use their middle finger to rotate a disc to get banana pellets. Even after a short time period (1 week) upon autopsy the monkeys had an enlarged region in their motor cortex. The conclusion: Even in adult monkeys, repeated physical behaviors stimulate neurogenesis in the motor cortex. This seemed like common sense. Not only do our brains shape our experiences, but our experiences shape the brain (literally).
As it turns out, neurogenesis slows with age, but it doesn’t stop. It continues throughout the lifespan. New learning stimulates cell birth and growth in the hippocampus (and other areas involving memory processing and storage). The “new brain research” left open the possibility that counseling and psychotherapy has the potential to stimulate neurochemical changes and cell birth in the human brain.
The evidence is no longer slowly rolling in—it’s popping like popcorn. Neuroscience research is as popular as Beyoncé. Whenever more evidence arrives showing how counseling and psychotherapy might be affecting brain functioning, non-medical mental health professionals get giddy. As you might suspect (or already know) occasionally we’re so excited that our statements about the implications and applications of neuroscience are way ahead of the actual scientific evidence. Counseling and psychotherapy practitioners have created new marketing terminology like “brain-based therapy” and “neurocounseling” and “interpersonal neurobiology” despite the lack of clear scientific evidence to support these terms. In some cases the birthing of this new terminology has caused lament within the neuroscience community (Satel & Lillienfeld, 2015).
Where does all this take us? As Dr. M would say, the brain is central to mood and behavior change. But now we know the reverse is also true: mood and behavior are central to brain development and change. If Dr. M were still alive, I might say, “touche” or “voila” or some other fancy and clever retort to show him that he had the directionality wrong—all these years.
But my retort would be incorrect too. The influence goes both directions at once. Even more importantly, we need to acknowledge that the relationships between and among brain structures, neurotransmitters, hormones, other chemicals, and human behaviors are still complex and mysterious. Even though journalists sometimes write with flourish about our ability to peer directly into the brain and see exactly what’s happening, that’s just not true. And to the extent we can “see” what’s happening, it appears that the brain is simultaneously functioning as a whole, as regions, as inter- and intra-cellular processes, and doing all these activities in particular sequences and all at once. Sure, as many mental health professionals will enthusiastically claim, we now know that meditation and interpersonal empathic experiences appear to stimulate the anterior insular cortex (AIC)! But it’s more complicated than that. The following excerpt from the neuroscience literature helps communicate this complexity (Mutschler, Reinbold, Wankerl, Seifritz, & Ball, 2013).
In summary, we argue that the dorsal AIC plays a pivotal role in empathy (similarly as during emotion processing and pain) by integrating sensory stimuli with its salience, possibly via connections to the cingulate cortex. This assumption is also supported by the fact that ALE-findings related to emotion and empathy for pain and also the DGR—which has been associated with cognition—overlap in the dorsal anterior insula, suggesting that these functions share a common neural substrate . . . . As mentioned above we assume that the overall role of the morphometrically identified area in the dorsal AIC related to individual differences in empathy which overlaps the DGR might be involved in integrating information which is relevant for socio-emotional and cognitive processing. Thus, we assume that empathy is not (only) related to a specific “socio-emotional” interaction area, but to a superordinate “domain-general” area, in line with concepts of empathy that include not only social and emotional, but also cognitive aspects . . . . Whether our findings in the dorsal AIC have also a relation to the “von Economo neurons” [VENs, . . .] remains to be determined. VENs have been hypothesized to play are role in social-emotional processing including empathy . . . .
This excerpt should inspire us all to pause with respect for the density and specificity of neuroscience. It should also inspire us to ramp down our expectations. If we just focus on empathy and the insula, we can see many sources of potential error: (a) much of the empathy research focuses on empathy for pain; (b) empathy is hard to measure; (c) it’s possible for a human brain to “light up” with empathy, but for the human to not express or show empathy toward someone else; (d) while empathy is generally considered a positive quality, some people use empathy to manipulate and hurt others; (e) there is brain structural and functional overlap; (f) the role of the VENs is unknown; and on and on. To use an inappropriate metaphor, it’s likely that the particular blend and balance of neurotransmitters (there may be up to 100) and hormones (there are about 50) and other cellular substances in each individual—along with structural variability—is more unique than a fingerprint on a snowflake.
In every chapter of this text Charles Luke (of Tennessee Tech) and I will share a highlight or update on neuroscience research. These highlights and updates will focus not only on the promise and potential of neuroscience to counseling and psychotherapy, but also on its limitations. A focus on limitations is needed because our ability to imagine what’s happening in the brain greatly outpaces neuroscience research. Although it’s tempting (and terribly fun), we shouldn’t let our imagination get too far in front of the science. As Dr. M might have said, “the brain offers us the greatest opportunity and potential to understand, explain, predict, and manage human behavior.” Of course it does; and it always will.
Happy Sunday morning. I’m at my standing desk, working on the revision of our Counseling and Psychotherapy Theories text. What fun. Actually, because I’ve been getting great and constructive feedback from many different reviewers, THIS IS much more fun than it might be otherwise.
Today I’m posting a potential new start to the theories text. It came to me because some academics have questioned the value of teaching counseling and psychotherapy theories. If you’re interested, I’d love to hear your opinion on that. Also, if you have feedback on whether the following piece makes for a good start to a theories text (or not), I’d love to hear your opinion on that too.
Here it is:
Why Learn Theories?
About a decade ago, I (John) was flying back from a professional conference when a professor (we’ll call him Darrell) from a large Midwestern university spotted an empty seat next to me. He sat down, and being aware that I have a book on counseling and psychotherapy theories, initiated the sort of conversation that probably only happens among counseling, psychology, or social work professors.
He plunged right in, “I think counseling and psychotherapy theories are passé. There has to be a better way to teach students how to actually do counseling and psychotherapy.”
When confronted like this, I like to pretend I’m Carl Rogers, so I paraphrased, “You’re thinking there’s a better way.”
“Yes!” he said. “All the textbooks start with Freud and crawl their way to the present. Too much time is wasted reviewing outdated theories that were developed by old White men. What’s the point of that?”
“The old theories seem pointless to you.” I felt congruent with my inner Rogers.
“Worse than pointless,” he glared, “they’re not just unnecessary; they’re destructive! We live in a diverse culture. Those theories weren’t built for today. I’m a White heterosexual male and they don’t even fit for me. We need to focus our students on empirically-supported treatments and then teach them the technical skills they need to implement those approaches. We live in a time and a place that values action and effectiveness. That’s what our clients want and deserve. For the next edition of your theories text you should put traditional theories of counseling and psychotherapy in the dumpster where they belong.”
I lost my connection to Carl Rogers and was about to go all Albert Ellis on him when the intercom crackled to life. The flight attendant directed everyone to return to their seats. My academic colleague reluctantly rose and bid me farewell.
On the surface, Darrell’s argument is compelling. Counseling and psychotherapy theories must adjust themselves to address unique issues of women as well as racial, ethnic, sexual, and religious minorities. Theories also need to be more practical. “Crusty” old theories need updating and need to be more user-friendly. Students should be able to read a theories chapter and finish with a clear sense of how to apply that theory in practice.
But Darrell’s argument is also off target. Although he’s advocating an evidence-based (scientific) orientation, he doesn’t seem to appreciate the central role of theory to science. As Carl Zimmer (2016) of the New York Times recently wrote: “Theories are neither hunches nor guesses. They are the crown jewels of science” (p. D6).
Counseling and psychotherapy theories are well-developed systems for understanding, explaining, predicting, and controlling human behavior. When someone on Twitter writes, “I have a theory, that cats are actually in a liquid state some of the time,” it’s not a theory (Zimmer, 2016). More likely, it’s a thought or a guess or a goofy statement pertaining to that person’s idiosyncratic take on reality. It might be a fascinating thought or statement, but it’s still not a theory.
Instead of “crown jewels,” we like to think of theories as the “foundations” from which we build our understanding of human development, suffering, self-destructive behavior, positive change, and other human experiences. Without theory, we can’t understand why people engage in self-destructive behaviors or why they sometimes suddenly stop engaging in those behaviors. If we can’t understand why people behave in certain ways, then our ability to identify and apply effective treatments is compromised. In fact, every evidence-based or empirically-supported approach that exists rests on the shoulders of counseling and psychotherapy theories.
In life and psychotherapy, there are often repeating patterns. I recall making an argument similar to Darrell’s, way back in the 1980s. I complained to a professor that I just wanted to focus on learning the essentials of becoming a great therapist. Her feedback was direct: I could become a technician who applied specific procedures to people with specific problems or I could grapple with deeper issues and become a real therapist with a more profound understanding of human problems, who could articulate the benefits and limitations of specific psychological change strategies, and who could modify those strategies to fit unique and diverse clients.
Just like Darrell, my professor was biased, but in the opposite direction. She valued nuance, human mystery, and existential angst. She devalued what she viewed (at the time) as the superficiality of behavior therapy.
Looking back, I can see both perspectives. Therapists need technical skills for implementing research-based treatments. But we also need respect and empathy for the idiosyncratic individual who comes to us for compassion and insight. We need to be able to view clients and problems from many perspectives—ranging from the indigenous to the contemporary medical model. To be really good at applying specific technical skills, we need to understand the nuance and dynamics of psychotherapy and how human change happens. And in the end, that means we need to study theories.
Contemporary Theories, Not Pop Psychology
Despite Darrell’s argument that traditional theories belong in the dumpster, all the theories in this text—even the old ones—are contemporary and relevant. They’re contemporary because they (a) have research support and (b) have been updated or adapted for working with diverse clients. They’re relevant because they include specific strategies and techniques that facilitate emotional, psychological, and behavioral change. Although some of these theories of human development and change are more popular than others, they shouldn’t be confused with “pop” psychology. In fact, these theories usually aren’t well understood or accurately portrayed in the popular media.
Another reason why these theories don’t belong in the dumpster is because they’re exciting and intellectually stimulating. Put simply, the drama associated with the development and application of these theories rivals anything Hollywood has to offer. The theories in this text are woven into and derived from great literature, myth, religion, and our dominant and minority political and social systems. They can explain and predict ways we interact with each other, including how we define mental health, whether we believe in mental illness, and our views on love, meaning, death, rehabilitation, and personal responsibility. They also help us answer big questions like:
- What motivates people to do what they do?
- What disturbs thinking processes, triggers unmanageable anger, diminishes personal productivity, and destroys relationships?
- What causes one person to be satisfied with a simple and cheerful life, while others claw their way ruthlessly to the top?
- What makes some people come out stronger after facing tragedy or hardship, while others are weakened or permanently damaged?
If you’ve come this far in your studies of psychology and counseling, you know there’s no single answer to these questions. It’s common for mental health professionals to strongly disagree with each other on just about every topic under the sun. Therefore, it should be no surprise that this book—a book about the major contemporary theories and techniques of psychotherapy and counseling—will contain stunning controversies and conflict. In the following pages, we do our best to bring you more than just the theoretical basics; we also bring you the thrills and disappointments linked to these theories of human motivation, functioning, and change.
Over the past five years I’ve written over 50 blog posts linked to teaching and learning the theory and practice of counseling and psychotherapy. While procrastinating on another project, I decided to organize these blog posts by topic. If you follow the links below, they’ll take you to blog posts relevant to specific theories. Included in some of these are a few links to short (and free) theories-based video examples. If you teach a theories course, you could select some of these links to assign students outside readings or you could peruse them yourself to stimulate a few lecture ideas.
Please note that if you use our Counseling and Psychotherapy Theories in Context and Practice textbook, there’s a bit of redundancy with the textbook’s content. However, if you don’t use the text, the material will be new to you and your students.
Chapter 1 – Opening and Overview
A Plan for Maximizing Positive Counseling and Psychotherapy Outcomes: https://johnsommersflanagan.com/2014/09/07/a-plan-for-maximizing-positive-counseling-and-psychotherapy-outcomes/
Teaching Counseling and Psychotherapy Theories: Reflections on Week 1: https://johnsommersflanagan.com/2012/08/29/teaching-counseling-and-psychotherapy-theories-reflections-on-week-1/
Reformulating Clinical Depression: The Social-Psycho-Bio Model: https://johnsommersflanagan.com/2013/09/03/reformulating-clinical-depression-the-social-psycho-bio-model/
What’s the Difference between Counseling and Psychotherapy? https://johnsommersflanagan.com/2016/07/14/theories-highlights-i-whats-the-difference-between-counseling-and-psychotherapy/
Neuroscience New Year’s Resolutions: https://johnsommersflanagan.com/2016/01/15/neuroscience-new-years-resolutions-for-2016/
Evidence-Based Relationships in Counseling and Psychotherapy: https://johnsommersflanagan.com/2015/09/29/evidence-based-relationships-three-new-case-examples/
Chapter 2 – Psychoanalytic Approaches
Attachment-Informed Psychotherapy: https://johnsommersflanagan.com/2015/08/12/attachment-informed-psychotherapy/
The Story of Freud’s Seduction Hypothesis: https://johnsommersflanagan.com/2016/07/15/theories-highlights-ii-the-story-of-freuds-seduction-hypothesis/
The Working Alliance in Counseling and Psychotherapy: https://johnsommersflanagan.com/2016/04/06/five-recommendations-for-developing-a-positive-working-alliance/
Chapter 3 – Adlerian Approaches: Individual Psychology
The Three-Step Emotional Change Trick: https://johnsommersflanagan.com/2012/09/23/the-three-step-emotional-change-trick/
A Parenting Homework Assignment on Natural and Logical Consequences: https://johnsommersflanagan.com/2011/11/30/a-parenting-homework-assignment-on-natural-and-logical-consequences/
More Than Praise — Other Ways Parents Can Be Positive With Their Children: https://johnsommersflanagan.com/2012/08/16/more-than-praise-other-ways-parents-can-be-positive-with-their-children/
Chapter 4 – Existential Approaches
Reflections on Listening to Irvin Yalom at the ACA Conference: https://johnsommersflanagan.com/2012/03/25/reflections-on-listening-to-irvin-yalom-at-the-aca-conference/
A Short Existential Case Example from Counseling and Psychotherapy Theories . . .: https://johnsommersflanagan.com/2015/08/25/a-short-existential-case-example-from-counseling-and-psychotherapy-theories/
Fun with Existential Theory: https://johnsommersflanagan.com/2016/08/01/fun-with-existential-theory/
Chapter 5 – Person-Centered Approaches
Reflections on Magic: https://johnsommersflanagan.com/2011/11/28/reflections-on-magic/
Listening as Meditation on Psychotherapy.net: https://johnsommersflanagan.com/2014/02/25/listening-as-meditation-on-psychotherapy-net/
An Interview with Natalie Rogers (Daughter of Carl Rogers) about Person-Centered Therapy: https://johnsommersflanagan.com/2015/08/04/an-interview-with-natalie-rogers-daughter-of-carl-rogers-about-person-centered-therapy/
Why Therapists Should Never Say, “I know how you feel”: https://johnsommersflanagan.com/2013/05/30/why-therapists-should-never-say-i-know-how-you-feel/
Carl Rogers and Brain-Science do an Empathy Smackdown in Chapter 3: https://johnsommersflanagan.com/2015/07/09/carl-rogers-and-brain-science-do-an-empathy-smackdown-in-chapter-3/
An Invitation for Collaboration: https://johnsommersflanagan.com/2016/03/27/using-an-invitation-for-collaboration-in-counseling-and-psychotherapy/
Chapter 6 – Gestalt Approaches
Go Go Gestalt: The Theories Video Shoot, Part I: https://johnsommersflanagan.com/2012/04/24/go-go-gestalt-the-theories-video-shoot-part-i-2/
Chapter 7 – Behavioral Approaches
A Black Friday Tribute to Mary Cover Jones and her Evidence-Based Cookies: https://johnsommersflanagan.com/2011/11/25/a-black-friday-tribute-to-mary-cover-jones-and-her-evidence-based-cookies/
Behavioral Activation Therapy: Let’s Just Skip the Cognitions: https://johnsommersflanagan.com/2014/06/30/behavioral-activation-therapy-lets-just-skip-the-cognitions/
Imaginal or In Vivo Exposure and Desensitization: https://johnsommersflanagan.com/2012/05/19/imaginal-or-in-vivo-exposure-and-desensitization-2/
A New Look at Time-Out for Kids and Parents: https://johnsommersflanagan.com/2012/08/04/a-new-look-at-time-out-for-kids-and-parents/
Information on Using Time-Out — Part II: https://johnsommersflanagan.com/2012/08/05/information-on-using-time-out-part-ii/
Talking with Parents about Positive Reinforcement: https://johnsommersflanagan.com/2014/09/06/talking-with-parents-about-positive-reinforcement/
Backward Behavior Modification: https://johnsommersflanagan.com/2012/12/02/backward-behavior-modification/
Chapter 8 – Cognitive-Behavioral Approaches
Positive Thinking is Not (Necessarily) Rational Thinking: https://johnsommersflanagan.com/2011/12/06/positive-thinking-is-not-necessarily-rational-thinking/
How to Use the Six Column CBT Technique: https://johnsommersflanagan.com/2014/02/18/how-to-use-the-six-column-cbt-technique/
A Quick Look at the Collaborative Cognitive Therapy Process: https://johnsommersflanagan.com/2012/09/30/a-quick-look-at-the-collaborative-cognitive-therapy-process/
Tomorrow’s Election and Confirmation Bias: https://johnsommersflanagan.com/2012/11/05/tomorrows-election-and-confirmation-bias/
Confirmation Bias on My Way to Spearfish, South Dakota: https://johnsommersflanagan.com/2014/04/30/confirmation-bias-on-my-way-to-spearfish-south-dakota/
Chapter 9 – Choice Theory and Reality Therapy
The Seven Magic Words for Parents: https://johnsommersflanagan.com/2012/12/23/the-seven-magic-words-for-parents/
Give Information and then Back-Off: A Choice Theory Parenting Assignment: https://johnsommersflanagan.com/2012/07/09/give-information-and-then-back-off-a-choice-theory-parenting-assignment/
How Parents Can Use Problem-Solving Power: https://johnsommersflanagan.com/2012/10/23/how-parents-can-use-problem-solving-power/
Chapter 10 – Feminist Approaches
Opening Thoughts on Feminism: https://johnsommersflanagan.com/2012/04/03/opening-thoughts-on-feminism-3/
The Girl Code by Ashley Marallo: https://johnsommersflanagan.com/2012/12/03/the-girl-code-by-ashley-marallo/
A Guest Essay on the Girl Code and Feminism: https://johnsommersflanagan.com/2014/12/07/a-guest-essay-on-the-girl-code-and-feminism/
Feminist Culture in Music: https://johnsommersflanagan.com/2013/11/18/feminist-culture-in-music/
Chapter 11 – Constructive (Solution-Based and Narrative) Approaches
Is Solution-Focused Therapy as Powerfully Effective as Solution-Focused Therapists Would Have Us Believe?: https://johnsommersflanagan.com/2012/07/01/is-solution-focused-therapy-as-powerfully-effective-as-solution-focused-therapists-would-have-us-believe-2/
Secrets of the Miracle Question: https://johnsommersflanagan.com/2015/03/04/secrets-of-the-miracle-question/
The Love Reframe: https://johnsommersflanagan.com/2013/04/07/the-love-reframe/
Constructivism vs. Social Constructionism: What’s the Difference? https://johnsommersflanagan.com/2015/12/05/constructivism-vs-social-constructionism-whats-the-difference/
Chapter 12 – Family Systems Approaches
None posted on this topic. Obviously, I need help here.
Chapter 13 – Multicultural Approaches
Four Good Ideas about Multicultural Counseling and Psychotherapy—In Honor of Martin Luther King, Jr.: https://johnsommersflanagan.com/2012/01/16/four-good-ideas-about-multicultural-counseling-and-psychotherapy-in-honor-of-martin-luther-king-jr/
Good Ideas about Multicultural Counseling and Psychotherapy – Part II: https://johnsommersflanagan.com/2012/01/22/good-ideas-about-multicultural-counseling-and-psychotherapy-part-ii/
Cultural Adaptations in the DSM-5: Insert Foot in Mouth Here: https://johnsommersflanagan.com/2014/07/08/cultural-adaptations-in-the-dsm-5-insert-foot-in-mouth-here/
Psychic Communications . . . and Cultural Differences in Mental Status: https://johnsommersflanagan.com/2013/01/02/psychic-communications-and-cultural-differences-in-mental-status/
A White Male Psychologist Reflects on White Privilege: https://johnsommersflanagan.com/2012/09/14/a-white-male-psychologist-reflects-on-white-privilege/
Tips for Counseling Culturally Diverse Youth: https://johnsommersflanagan.com/2015/11/19/counseling-culturally-diverse-youth-research-based-and-common-sense-tips/
Chapter 14 – Integrative Approaches
Making Memories in L.A.: An Interview with Matt Englar-Carlson: https://johnsommersflanagan.com/2016/05/20/making-memories-in-l-a/
My Response to a Petition from a Theories Class at Xavier University: https://johnsommersflanagan.com/2016/04/29/why-xavier-university-students-in-cincinnati-sent-me-a-petition/
This week I’m back to reviewing the page proofs for the 6th edition of Clinical Interviewing. It’s tons of fun. I’m consistently surprised when I find typos or bad sentences in material that I’ve already reviewed five times previously. Ugh. Oh well. Life is generally good . . . and once in a while I run into some interesting new content that I think is worth sharing. Here’s one excerpt. It’s toward the end of Chapter 4, titled: “Nondirective Listening Skills.” The 6th edition is coming soon: https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=sr_1_5?s=books&ie=UTF8&qid=1470784556&sr=1-5&keywords=clinical+interviewing
Ethical and Multicultural Considerations
It’s likely that each client will respond to you and your listening skills differently. Some clients will love having you as a listener. They’ll be instantly impressed with your excellent interviewing skills. Other clients will be neutral. Still others will think (and possibly tell you) that your education and training are worthless and that they resent having to spend time with you.
The Ethics of Not Directing
Listening well is an essential therapeutic skill, but many clients don’t come for counseling looking for an excellent listener. They come because they want an expert. They desire guidance. They may even want to be told what to do and how to do it.
The desire for an authoritative counselor may be particularly salient within ethnic and cultural groups. For example, Asian American clients tend to want more direct guidance from their counseling professionals (Chang & O’Hara, 2013). Of course this is a generalization, but knowing that some Asian clients want an expert and will be disappointed if you don’t act in more directive ways is valuable information.
Some presenting problems, such as those present in crises or severe mental disorders, also might require more active and directive interventions. Cultural and personal expectations, presenting problem(s), and theoretical orientations can call for more directive, authoritative interactions. If so, it might be unethical for you to persist with nondirective listening and not advance to the skills and techniques described in Chapters 5 and 6. See Case Example 4.2 for a concrete example.
Case Example 4.2: When Being Nondirective Might Be Unethical
While reading the referral information, you discover that your new client is a seventeen-year-old Chinese American female with a history of cutting and parasuicidal behavior. Early in the interview she tells you, “I want to stop cutting.” This is especially good news because you know something about skills training for clients who cut. Although your active listening provides an excellent foundation, if you only listen to her, you’ll be doing her a disservice. The point is this: If you know about something that fits with your client’s specific condition and you withhold it without an exceptionally good rationale, you’re in ethical hot water. In this case, you should actively begin teaching your client alternative emotional management skills.
In another situation, you could make a case for withholding your advice and being less direct. For example, if your client is Native American and rapport development is slow and you’re not certain that she’s motivated to stop cutting, you would have a solid rationale for maintaining a nondirective listening stance with plenty of self-disclosure and a focus on developing a working alliance. Staying less direct with Native clients and respecting their process are reasonable strategies. Your client might not be ready or willing to work on developing alternative coping strategies until session 2 or 3 or 4. If you were to jump in too soon with advice on how to stop cutting, your client might not show up for session 2.
Gender, Culture, and Emotion
Imagine that you’re in an initial clinical interview with a Latino male. Your impression is that he’s angry about his wife’s employment outside the home. You’re aware that some Latinos have more traditional ideas about male and female roles in the home. This knowledge provides you with evidence to support your hypothesis about your client’s emotional state. So you intentionally use a reflection of feeling to focus in on your client’s anger:
I’m getting the sense that you’re a little angry about your wife deciding to go back to work.
Nah. She can do whatever she wants.
You hear his words. He seems to be empowering his wife to do as she pleases. But his voice is laden with annoyance. This leads you to try again to connect with him on a deeper level. You say,
Right. But I hear a little annoyance in your voice.
This reflection of feeling prompts an emotional response, but not the one you had hoped for.
Sure. You’re right. I am annoyed. I’m fucking annoyed with you and the fact that you’re not listening to me and keep focusing on all this feelings shit.
This is a dreaded scenario for many clinicians. You take a risk to reflect what seems like an obvious emotion, and you get hostility in return. For several possible reasons, your emotional sensitivity backfires. The client moves to a defensive and aggressive place, and a relationship rupture occurs (see Chapter 7 for more on dealing with relational ruptures).
It’s tempting to use culture and gender to explain this client’s negative reaction to your reflection of feeling. But it’s not that simple.
Although culture, gender, race, and other broad classification-based variables can sometimes predict whether a specific client will be comfortable with emotional expression, individual client differences are probably more substantial determinants. In particular, comfort in expressing emotion is often a function of whether the client comes from a family-neighborhood-cultural context where emotional disclosure was a norm. For example, Knight (2014) reported that black and Latino males who were unlikely to disclose to their peers attributed this tendency directly to their experiences living in violent communities. These young men had learned that emotional expression and trusting others were bad ideas in their neighborhoods. Conversely, emotional disclosure is more likely to be in the comfort range of black and Latino males who are raised in safer community environments. This makes good common sense: Whether clients perceive you as safe to talk with about emotional concerns probably has more to do with the clients’ background and past experiences than it has to do with you.
Overall, it’s likely that clients’ willingness to tolerate feeling reflections is based on a mix of their cultural, gender, and individual experiences. To move these ideas toward application, if you have reason to suspect that your client is less comfortable focusing on emotions, you should avoid words that are emotionally specific and therefore more provocative. Examples of emotionally specific words include angry, sad, scared, and guilty.
Instead of using emotionally specific words, you can initially substitute words that are emotionally vague (and less intense). Later, as trust develops, it may be possible to use more specific emotional words. Consider the following phrases:
- You found that frustrating.
- It seems like that bothered you a bit.
- It’s just a little upsetting to think about that.
Putting It in Practice 4.4 lists examples of emotionally vague words you might use instead of emotionally specific words.
Putting It in Practice 4.4: Using Vague and Emotionally Safe Words
Emotionally Specific Words Substitute (Safer) Words
Angry Frustrated, upset, bothered, annoyed
Sad Down, bad, unlucky, “that sucked”
Scared Bothered, “didn’t need that,” “felt like leaving”
Guilty Bad, sorry, unfortunate, “bad shit”
Embarrassed Less than comfortable, bugged, annoyed
Note: These words may work as substitutes for more emotionally specific words, but they also may not. It will be more effective for you to work with your classmates or work setting to generate less emotionally threatening words and phrases that are culturally and locally specific.
Today I had the honor and privilege of chairing an APA symposium in Denver, titled: Publishing Books on Psychotherapy: Insights and Strategies from Psychologist-Authors
The cool part was that I got to listen to and comment on Melba J. Vasquez, Derald Wing Sue, and John C. Norcross as they shared their ideas about how to publish books. The other cool part was that this symposium was attended by most of the other people I know and recognize at this APA conference: Nick Heck and Nick Livingston (both grads of the U of Montana’s doc program in clinical psych) and Jerry and Marianne Corey—who just happened to drop by.
In addition to listening to three amazing authors talk about publishing, I also had a short presentation . . . and so here it is:
Publishing Books on Psychotherapy: Tips from John Sommers-Flanagan
Tip 1: Get your Writer Identity on: Writing as Professional Identity. It’s a good idea to have excellent writing role models. That’s the whole point of today’s symposium. Melba Vasquez, Derald Wing Sue, and John Norcross are perfect examples of excellent writing role models. My best first advice on writer identity is for you to have at least one role model from a distance and one close to home. Even better (maybe), being in a local or online writer’s group can get you moving toward having a WRITER identity.
One way of thinking about identity is the concept of intersectionality. The old magic 8-ball can be a useful metaphor. For most of us, many different parts of our identity are “present” most the time. There could be LGBTQ, ethnicity, familial values, age, ability/disability, occupational components, etc. Usually one or two of these “pop” up and guide our behavior. As Mary Pipher wrote (paraphrasing now)—if you want to be a writer, you need to begin thinking of yourself as a writer. That means one of the sides on that multidimensional or intersectional piece of your personal identity 8-ball should say: “Writer.” For me, one way I’ve embraced this idea is to ALWAYS (as much as I can) act like a writer. That means I proofread EVERYTHING I write, even emails! Check out this link to my blog for two readings on writer identity: https://johnsommersflanagan.com/2013/09/08/on-being-or-becoming-a-writer-again/
Tip 2: Face your Fears: Writing as an Act of Courage. Rejection sucks. This is true for nearly everyone. The sort of rejection that especially sucks is the rejection that comes when you’re feeling vulnerable. And writing, because it can be very personal and something you deeply identify with, can be a BIG place of vulnerability. The great writer, Cynthia Ozick once wrote that writing is essentially, “an act of courage.” So make a plan for dealing with your fears and bolstering your courage and keep on writing. Feedback can be hard. But without feedback, it’s harder to grow and develop as a writer. If you like, check out this blog post on rejection: https://johnsommersflanagan.com/2016/05/13/professional-writing-101-dealing-with-rejection/
Tip 3: Say What You’ll Do and Do What You Said: Writing as Professional Discipline. The most popular mantra for writers is: “Writer’s write.” Well okay. That’s a good idea . . . but it’s hard to find your destination without a plan or a map. So let’s be good behavioral scientists and make a clear plan (including positive reinforcements) for how to achieve that general goal. When will you write? Where will you write? What time of day is best for you? Standing, sitting, coffee shop, private space? How will you reward yourself after or during an excellent writing day? One of the best goals for writers who want to write is to set a 300 words a day goal. That way you write at least a bit every day, and can always write more on good days when the opportunity presents itself or the muse is with you. Another part of being a disciplined writer is to be good at the grammar part of writing. Don’t forget to consult Grammar Girl, a positive online resource. Here’s a blog that touches on APA style. https://johnsommersflanagan.com/2013/09/23/the-active-voice-in-writing-an-apa-style-blog/
Tip 4: Choose with Whom You Schmooze: Writing as Relationship. If you’re at the APA conference (today) or any other national conference (in the future), you’ll find the exhibition hall is filled with book publishers. If writing a book in psychology or counseling is a goal for you, now is not the time to be shy. Many book publishers are looking for new authors and book proposals. They all have their own particular book-writing guidelines. When you’re at a conference, go to the exhibit hall, hang out, schmooze, see what different publishers are looking for in a proposal, and talk about your excellent ideas. In most cases, you have a better chance of publishing a book if you know the publisher and the people who represent the publisher.
John Sommers-Flanagan is a Professor of Counselor Education at the University of Montana and a clinical psychologist. He is coauthor (with his wife, Rita) of the following books published with John Wiley & Sons: Clinical Interviewing (2017, 6th edition forthcoming); Counseling and Psychotherapy Theories in Context and Practice (2012, 2nd edition; 3rd edition forthcoming in 2018); How to Listen so Parents will Talk and Talk so Parents will Listen (2011); and Becoming an Ethical Helping Professional (2007).
I think existentialists have gotten a bad rap over the years. They don’t deserve their depressive reputation. If you’re not sure about this claim, invite a bunch of existentialists over for a party. They know how to have a good time. Just think of Jean Paul Sartre and Simone de Beauvoir. I’m sure they did some table-dancing (among other things) in their time.
Why are they so much fun? Well, in addition to their tendency to go on and on about death and meaninglessness, existentialists were some of the original embracers of carpe diem. They believe in seizing the day (or moment)–regardless of whether they’re playing Pokemon Go or working with you in counseling or psychotherapy.
Below I’ve included a short excerpt from the upcoming 3rd edition of Counseling and Psychotherapy Theories in Context and Practice. One of the reasons I’m posting this is because one of the reviewers of the 2nd edition noted that we were trying too hard to to be “cute” . . . so I thought I’d see if any of you blog-readers think that’s the case. This particular excerpt is as cute as we get in this chapter. What do you think?? Overboard? Just right? Or should we try to be more like Stephen Colbert. You be the judge in this moment in time.
As noted previously, there’s no single theorist or theory of existential psychotherapy. Consequently, although we focus on key existential philosophical and phenomenological principles, other existential writers and theorists may emphasize principles slightly different from the following.
The I-Am Experience
The I-am experience is the experience of being, of existing (R. May et al., 1958). The experience of being is often referred to as ontological experience (ontos means “to be” and logical means “the science of”). Literally, then, a major focus of existential therapy consists of exploring immediate human experience. You might think of it as suddenly waking up and being completely tuned into what it’s like to exist and be here and now in this particular moment in time.
Existentialists like to use hyphens to capture the interconnectedness of phenomenological experience. For example, in contrast to May’s I-am experience, Boss (1963) and Binswanger (1933) used Dasein (which is translated to being-in-the-world) to describe the sense-of-existence. Also, the phrase, “Dasein choosing,” which is translated to the-person-who-is-responsible-for-his-existence choosing is used. We should note that this practice is in no way related to our own hyphenated last names, although it has inspired John to consider adding a hyphenated middle name so he can refer to himself in the third person as, “John-who-is-responsible-for-his-existence-Sommers-Flanagan,” which he thinks sort of rolls right off the tongue.
It follows, as-if-anything-really-follows-from-the-preceding, that existential therapy is almost always in the service of self-awareness or self-discovery. However, unlike psychoanalysts, existentialists seek to expand client self-awareness rather than interpreting client unconscious processes. This is because existentialists believe the entirety of an individual’s human experience is accessible to consciousness. It’s not so much a matter of uncovering an elusive unconscious as it is a matter of elucidating the conscious and deepening the relational.
Four Existential Ways of Being
There are four primary existential ways of being-in-the-world. They include:
- Umwelt: Being-with-nature or the physical world.
- Mitwelt: Being-with-others or the social world.
- Eigenwelt: Being-with-oneself or the world of the self.
- Uberwelt: Being-with-the-spiritual or over world.
The first three of these existential ways of being were described by Boss (1963), Binswanger (1963), and May et al. (1958). The fourth way of being was added by van Deurzen (1988).
These four dimensions of existence are ubiquitous and simultaneous. Some people focus more on one dimension than others or shift from one to another depending on particular intentions or situations. For example, while on a mountain hike up the Stillwater gorge in Montana, it’s difficult not to become profoundly into being-with-nature as water powerfully cascades around you, making all conversation (being-with-others) impossible. However, depending on other factors, this experience can take people inward toward eigenwelt, toward an uberwelt spiritual experience, or stimulate a deep mitwelt (albeit a nonverbal one). In most cases the direction that your being moves in a given situation is likely a combination of several factors, including, but not limited to: anxiety, previous experiences, intention, as well as your spiritual predisposition.