What You Missed in Cincinnati: Part II


While in Cincinnati, I ran short on time and we missed a chance to watch a video clip on “Generating Behavioral Alternatives.” And so as a substitute, I’m posting the verbatim script of the clip we were supposed to watch, and although we’ll miss out on discussing, the clip is fun on its own. Here it’s an excerpt from our Counseling and Psychotherapy Theories book and placed in the context of “Problem-Solving Therapy.”

Generating Behavioral Alternatives With an Aggressive Adolescent

As noted previously, problem-solving therapy (PST) focuses on teaching clients steps for rational problem solving. In this case vignette, the therapist (John) is trying to engage a 15-year-old White male client in stage 2 (generating solutions) of the problem-solving model. At the beginning of the session, he client had reported that the night before, a male schoolmate had tried to rape his girlfriend. The client was angry and planning to “beat the s*** out” of his fellow student. During the session, John worked on helping the boy identify behavioral alternatives to retributive violence.

The transcript below begins 10 minutes into the session.

Boy: He’s gotta learn sometime.

JSF: I mean. I don’t know for sure what the absolute best thing to do to this guy is . . . but I think before you act, it’s important to think of all the different options you have.

Boy: I’ve been thinking a lot.

JSF: Well, tell me the other ones you’ve thought of and let’s write them down so we can look at the options together.

Boy: Kick the shit out of him.

JSF: Okay, I know 2 things, actually maybe 3, that you said. One is kick the [crap] out of him, the other one is to do nothing . . .

Boy: The other is to shove something up his a**.

JSF: And, okay—shove—which is kinda like kicking the s*** out of him. I mean to be violent toward him. [Notice John is using the client’s language.]

Boy: Yeah, Yeah.

JSF: So, what else?

Boy: I could nark on him.

JSF: Oh.

Boy: Tell the cops or something.

JSF: And I’m not saying that’s the right thing to do either. [Although John thinks this is a better option, he’s trying to remain neutral, which is important to the brainstorming process; if the client thinks John is trying to “reinforce” him for nonviolent or prosocial behaviors, he may resist brainstorming.]

Boy: That’s just stupid. [This response shows why it’s important to stay neutral.]

JSF: I’m not saying that’s the right thing to do . . . all I’m saying is that we should figure out, cause I know I think I have the same kind of impulse in your situation. Either, I wanna beat him up or kinda do the high and righteous thing, which is to ignore him. And I’m not sure. Maybe one of those is the right thing, but I don’t know. Now, we got three things—so you could nark on him. [John tries to show empathy and then encourages continuation of brainstorming.]

Boy: It’s not gonna happen though.

JSF: Yeah, but I don’t care if that’s gonna happen. So there’s nark, there’s ignore, there’s beat the s**. What else?

Boy: Um. Just talk to him, would be okay. Just go up to him and yeah . . . I think we need to have a little chit-chat. [The client is able to generate another potentially prosocial idea.]

JSF: Okay. Talk to him.

Boy: But that’s not gonna happen either. I don’t think I could talk to him without, like, him pissing me off and me kicking the s*** . . . [Again, the client is making it clear that he’s not interested in nonviolent options.]

JSF: So, it might be so tempting when you talk to him that you just end up beating the s*** out of him. [John goes back to reflective listening.]

Boy: Yeah. Yeah.

JSF: But all we’re doing is making a list. Okay. And you’re doing great. [This is positive reinforcement for the brainstorming process—not outcome.]

Boy: I could get someone to beat the s*** out of him.

JSF: Get somebody to beat him up. So, kind of indirect violence—you get him back physically—through physical pain. That’s kind of the approach.

Boy: [This section is censored.]

JSF: So you could [do another thing]. Okay.

Boy: Someone like . . .

JSF: Okay. We’re up to six options. [John is showing neutrality or using an extinction process by not showing any affective response to the client’s provocative maladaptive alternative that was censored for this book.]

Boy: That’s about it. . . .

JSF: So. So we got nark, we got ignore, we got beat the s*** out of him, we got talk to him, we got get somebody else to beat the shit out of him, and get some. . . . [Reading back the alternatives allows the client to hear what he has said.]

Boy: Um . . . couple of those are pretty unrealistic, but. [The client acknowledges he’s being unrealistic, but we don’t know which items he views as unrealistic and why. Exploring his evaluation of the options might be useful, but John is still working on brainstorming and relationship-building.]

JSF: We don’t have to be realistic. I’ve got another unrealistic one. I got another one . . . Kinda to start some shameful rumor about him, you know. [This is a verbally aggressive option which can be risky, but illustrates a new domain of behavioral alternatives.]

Boy: That’s a good idea.

JSF: I mean, it’s a nonviolent way to get some revenge.

Boy: Like he has a little dick or something.

JSF: Yeah, good, exactly. [John inadvertently provides positive reinforcement for an insulting idea rather than remaining neutral.]

Boy: Maybe I’ll do all these things.

JSF: Combination.

Boy: Yeah.

JSF: So we’ve got the shameful rumor option to add to our list.

Boy: That’s a good one. (Excerpted and adapted from J. Sommers-Flanagan & R. Sommers-Flanagan, 1999)

This case illustrates what can occur when therapists conduct PST and generate behavioral solutions with angry adolescents. Initially, the client appears to be blowing off steam and generating a spate of aggressive alternatives. This process, although not producing constructive alternatives, is important because the boy may be testing the therapist to see if he will react with judgment (during this brainstorming process it’s very important for therapists to remain positive and welcoming of all options, no matter how violent or absurd; using judgment can be perceived and experienced as a punishment, which can adversely affect the therapy relationship). As the boy produced various aggressive ideas, he appeared to calm down somewhat. Also, the behavioral alternatives are repeatedly read back to the client. This allows the boy to hear his ideas from a different perspective. Finally, toward the end, the therapist joins the boy in brainstorming and adds a marginally delinquent response. The therapist is modeling a less violent approach to revenge and hoping to get the boy to consider nonphysical alternatives. This approach is sometimes referred to as harm reduction because it helps clients consider less risky behaviors (Marlatt & Witkiewitz, 2010). Next steps in this problem-solving process include:

  • Decision making
  • Solution implementation and verification

As the counseling session proceeds, John employs a range of different techniques, including “reverse advocacy role playing” where John plays the client and the client plays the counselor and provides “reasons or arguments for [particular attitudes] being incorrect, maladaptive, or dysfunctional” (A. M. Nezu & C. M. Nezu, 2013).

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