Working with Challenging Parents and Youth . . . and Loving It


Supplementary Handout – Adams State University – Alamosa, CO – 2/27/15
John Sommers-Flanagan, Ph.D., Professor
Department of Counselor Education, University of Montana
John.sf@mso.umt.edu
406-243-4263

I have lived some thirty years on this planet, and I have yet to hear the first syllable of valuable or even earnest advice from my seniors
— Henry David Thoreau

The following techniques and strategies are discussed in the workshop. More extensive information is included in the Tough Kids, Cool Counseling (2007) book published by ACA publications and other resources listed in the reference section.

1. Acknowledging Reality: Teenagers and some pre-teens are likely to be initially suspicious and mistrustful of adults – especially sneaky, manipulative, authority figures like clinical mental health or school counselors. To decrease distrust, it is important to simply acknowledge reality about the reasons for meeting, about the fact that you’re strangers, and to notice obvious differences between yourself and the teenager. Another way of thinking about acknowledging reality is that it’s a form of counselor transparency or congruence. Research on evidence-based relationships has indicated that transparency, congruence, or genuineness is a predictor of positive counseling or psychotherapy outcomes.

Following is an example of how you might talk about confidentiality with young clients and their parents or caretakers using the acknowledging reality principle. Notice that this example uses a very direct and open discussion of confidentiality issues:

You may have read about confidentiality on the registration forms, or you may have heard the word before, but I want to discuss it with you now anyway. Confidentiality is like privacy. That means what you say in here is private and personal and will not leave this office. Of course, I have a secretary and files, but my secretary also will keep information private and my files are locked and secure.

What I’m saying is: I won’t talk about what either of you say to me outside of here, except in a few rare situations where I’m legally or ethically required to speak with someone outside of this office. For example, if any of you are a danger to yourself, or to anyone else, I won’t keep that information private. Also, if I find out about child abuse or neglect that has happened or is happening, I won’t keep that information private either, but I’ll work with you to get the best help possible. Do you have any questions about confidentiality (privacy)?
Now (the counselor looks at the child/adolescent), one of the trickiest situations is whether I should tell your mom and dad about what we talk about in here. Let me tell all of you how I like to work and see if it’s okay with you. (Look back at parents) I believe your son (daughter) needs to be able to trust me. So, I’d like you to agree that information I give to you about my private conversations with him (her) be limited to general progress reports. In other words, aside from general progress reports, I won’t inform you of details of what your child tells me. Of course, if your child is planning or doing something that might be very dangerous or self-destructive. In those cases, I will tell your child (turn and look to child) that he (she) is planning something I feel very uncomfortable with and then we will have everyone (turn back to parents) come in for an appointment so we can all talk directly about whatever dangerous thing has come up. Is this arrangement okay with all of you? (pp. 30-31)

2. Sharing Referral Information: To gracefully talk about referral information with teens, therapists need to educate referral sources about how this practice will be used. Specifically, referral sources should be trained to give therapists information about clients that is both accurate and positive. If referral information from teachers, parents, or probation officers is especially negative, the therapist should screen and interpret the information so it is not overwhelming or off-putting to young clients. Simblett (1997), writing from a constructive perspective, suggested that if therapists are planning to share referral information with clients, they should warn and prepare referral sources about such a practice. If not, the referral sources may feel betrayed. Also, when sharing negative information about the client, it’s important for the counselor to have empathy and side with the client’s feelings, while at the same time, not endorsing the negative behaviors. For example, “I can see you’re really mad about your mom telling me all this stuff about you. I don’t blame you for being mad. I think I’d be upset too. It’s hard to have people talking about you, even if they might have good intentions.” Here’s a more extended case example of sharing referral information from the Tough Kids, Cool Counseling (2007) book:

A female counselor is meeting for the first time with a 16-year-old female client. Immediately after introducing herself and offering a summary of the limits of confidentiality, she states, “I’m sure you know I talked with your parents and your probation officer before this meeting. So, instead of keeping you in the dark about what they said about you, I’d like to just go ahead and tell you everything I’ve been told. This sheet of paper has a summary of all that (counselor holds up sheet of paper). Is it okay if I just share all this with you?”

After receiving the client’s assent, the counselor moves her chair alongside the client, taking care to respect client boundaries while symbolically moving to a position where they can read the referral information together. She then reviews the information, which includes both positive information (the client is reportedly likeable, intelligent, and has many friends) and information about the legal and behavioral problems the adolescent has recently experienced. After sharing each bit of information, she checks in with the client by saying, “It says here that you’ve been caught shoplifting three times, is that correct?” or “Do you want to add anything to what your mom said about how you will all of a sudden get really, really angry?” When positive information is covered, the counselor says thing like, “So it looks like your teachers think you’re very intelligent and say that you’re well-liked at school . . . do you think that’s true . . . are you intelligent and well-liked?” If referral information from teachers, parents, or probation officers is especially negative, the counselor should screen and interpret the information so it is not overwhelming or off-putting to young clients. (excerpted from Sommers-Flanagan and Sommers-Flanagan, 2007, p. 32)

3. Collaborative Goal-Setting: Working with adolescents or teenagers is different from working with adults. In this excerpt from a recently published article with Ty Bequette, we briefly focus on how the opening interaction with an adolescent client might look different than an opening interaction with an adult client. This is from: Sommers-Flanagan, J., & Bequette, T. (2013). The initial interview with adolescents. Journal of Contemporary Psychotherapy, 43(1), 13-22.

When working with adults, therapists often open with a variation of, “What brings you for counseling” or “How can I be of help” (J. Sommers-Flanagan & Sommers-Flanagan, 2012). These openings are ill-fitted for psychotherapy with adolescents because they assume the presence of insight, motivation, and a desire for help—which may or may not be correct.

Based on clinical experience, we recommend opening statements or questions that are invitations to work together. Adolescent clients may or may not reject the invitation, but because adolescent clients typically did not select their psychotherapist, offering an invitation is a reasonable opening. We recommend invitations that emphasize disclosure, collaboration, and interest and that initiates a process of exploring client goals. For example,

I’d like to start by telling you how I like to work with teenagers. I’m interested in helping you be successful. That’s my goal, to help you be successful in here or out in the world. My goal is to help you accomplish your goals. But there’s a limit on that. My goals are your goals just as long as your goals are legal and healthy.

The messages imbedded in that sample opening include: (a) this is what I am about; (b) I want to work with you; (c) I am interested in you and your success; (d) there are limits regarding what I will help you with. It is very possible for adolescent clients to oppose this opening in one way or another, but no matter how they respond, a message that includes disclosure, collaboration, interest, and limits is a good beginning.

Some adolescent clients will respond to an opening like the preceding with a clear goal statement. We’ve had clients state: “I want to be happier.” Although “I want to be happier” is somewhat general, it is a good beginning for parsing out more specific goals with clients. Other clients will be less clear or less cooperative in response to the invitation to collaborate. When asked to identify goals, some may say, “I don’t know” while others communicate “I don’t care.”

Concession and redirection are potentially helpful with clients who say they don’t care about therapy or about goal-setting. A concession and redirection response might look like this: “That’s okay. You don’t have to care. How about we just talk for a while about whatever you like to do. I’d be interested in hearing about the things you enjoy if you’re okay telling me.” Again, after conceding that the client does not have to care, the preceding response is an invitation to talk about something less threatening. If adolescent clients are willing to talk about something less threatening, psychotherapists then have a chance to listen well, express empathy, and build the positive emotional bond that A. Freud (1946, p. 31) considered a “prerequisite” to effective therapy with young clients.

Some adolescents may be unclear about limits to which psychotherapists influence and control others outside therapy. They may imbue therapists with greater power and authority than reality confers. Some adolescents may envision their therapist as a savior ready to provide rescue from antagonistic peers or oppressive administrators. Clarification is important:

Before starting, I want to make sure you understand my role. In therapy you and I work together to understand some of the things that might be bugging you and come up with solutions or ideas to try. But, even though I like to think I know everything and can solve any problem, there are limits to my power. For example, let’s say you’re having a conflict with peers. I would work with you to resolve these conflicts, but I’m not the police, and I can’t get them sent to jail or shipped to military school. I can’t get anyone fired, and I can’t help you break any laws. Does that make sense? Do you have any questions for me?

A clear explanation of the therapist’s role and an explanation about counseling process can allay uncertainties and fears about therapy. Inviting questions and allowing time for discussion helps empower adolescent clients, build rapport, and lower resistance.

4. Exploring and Understanding Early Memories (using the affect bridge): The affect bridge is designed to link current emotions with past emotions. Originally described as a hypnoanalytic technique by John Watkins (1971), the procedure can be used without a trance state to deepen your understanding of the origin and power of your client’s problematic affective states. The technique is simple and direct. For example, you might say: “You’re doing a great job telling me about some recent things that really make you mad. Now, tell me about an earlier time, when you were younger, when you felt similar feelings.” This technique or prompt will often elicit early memories that can then be used, similar to Adler’s early recollection method, to understand the client’s schema, cognitive map, or lifestyle.

5. Reflection of Emotions: Emotional reflections, a la Carl Rogers (1942, 1961), are very important in counseling adolescents. This is because most youth are just learning about themselves and calibrating their emotional selves. Emotional reflections serve at least a two-fold purpose: (a) they provide youth a chance to see/hear themselves in an emotional mirror, and (b) they provide youth with a chance to tell the therapist that he or she has it all wrong (a corrective function). If the therapist begins noticing that he or she is consistently getting the emotional and content reflections incorrect with a given client, an effort at emotional repair is warranted. This simply involves apologizing for being incorrect, appreciating the client’s efforts to correct the therapist and a statement of commitment to continue trying.

The first video clip in this workshop focuses on a single session conducted with “Meagan” a 16-year-old White female. This video clip is used to discuss the first five techniques, described above. Following is a short description of and commentary on the Meagan video clip, including portions of the session that are not included on the video.

During this session opening and during several of the openings illustrated on this videotape, I begin by acknowledging that Meagan and I are strangers, that we don’t know each other very well. This opening is simply an acknowledgment of reality and is used because teenagers often find it to be a bit of relief when an adult simply and directly acknowledges the reality of a situation.
Very early in the session, Meagan and I decide together to focus on her anger for the remainder of the session. I then ask her to describe an early memory of being very angry. This “early memory” technique is derived partly from Adlerian theory (Eckstein, 1999). However, the suggestion that Meagan focus on an “angry” early memory is an example of an “affect bridge.” The affect bridge technique was originally described by John G. Watkins (1971), a renowned hypnotherapist.
Meagan responds to the affect bridge technique by describing two different childhood anger episodes. Whether you agree with using a historically-oriented question or not, my purpose was to gather data to help me conceptualize her anger “buttons” or “triggers” or “activating events” (which is a reasonable purpose based on contemporary cognitive-behavioral anger management strategies; Ellis, 1987; Novaco, 1979). It may be interesting for you to think about whether using the historically-oriented affect bridge is acceptable from your personal therapeutic framework or theoretical orientation.
Although you don’t have an opportunity to watch this session (or any of the sessions) in its entirety, the remainder of the session includes the following:
• After the historical questions, I ask Meagan for a current anger example
• I use a case conceptualization technique with Meagan, wherein I tell her that I think her main “button” is related to having a strong reaction to acts of injustice (toward her or toward others). I use this conceptualization even though I recognize that there are also un-articulated abandonment and humiliation issues linked to her early memories of being angry. The main reasons for this choice include (a) the fact that we’re on video; (b) the brief nature of our counseling relationship; and (c) the fact that the deep issues come out so early.
• Meagan is very responsive to being described as a person very sensitive to injustice. She also resonates well with the idea of wanting to “teach others a lesson” when they engage in unjust or unfair behaviors.
• Toward the end of the session, I lead Meagan through a very brief relaxation procedure.
• The session ends with me giving Meagan an “identity suggestion.” Specifically, I ask her to consider that her idea of herself as someone who gets angry easily and quickly might be growing outdated. Instead, I ask her to begin thinking of herself as the kind of person who is calm and happy. I also ask her to keep practicing some breathing or relaxation techniques. (from: Sommers-Flanagan and Sommers-Flanagan, 2004)

6. Dealing with Initial Provocations: Adolescent clients are known for their ability to be provocative and push their counselor’s emotional buttons. For example:

Counselor: I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.
Client: You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response). (From Sommers-Flanagan and Bequette, 2013)

Think about how you might respond to this scenario. We (John and Rita) believe that if counselors are not aware of how they are likely to react to emotionally provocative situations (such as the preceding) and prepared to respond with radical acceptance, empathy, validation, and concession, they may not be well-suited to working with adolescent clients (Sommers-Flanagan & Richardson, 2011).

Nearly all adolescents have quick reactions to therapists and unfortunately these reactions are often negative, though some may be unrealistically positive (Bernstein, 1996). Adolescents may bristle at the thought of an intimate encounter with someone whom they see as an authority figure. Having been judged and reprimanded by adults previously, adolescents may anticipate the same relationship dynamics in psychotherapy. Therapists must be ready for this negative reaction (i.e., transference) and actively develop strategies to engage clients, lower resistance, and manage their own countertransference reactions (Sommers-Flanagan & Sommers-Flanagan, 2007).

7. What’s Good About You? This procedure provides an opportunity for a rich interpersonal interaction with teenage clients. It also generates useful information regarding child/adolescent self-esteem. I like to initially, introduce it as a “game” with specific rules: “I want to play a game with you. I’m going to ask you the same question 10 times. The only rule is that you cannot answer the question with the same answer twice. In other words, I’ll ask you the same question 10 times, but you have to give me 10 different answers.” When playing this game therapists simply ask their client, “What’s good about you?” (while writing down the responses), following each response with “Thank you” and a smile. If the client responds with “I don’t know” the therapist simply writes down the response the first time, but if the client uses “I don’t know” (or any response) a second time, the therapist reminds the client, in a light and possibly humorous manner, that he or she can use answers only one time. As with all techniques, this should be used with client consent or agreement. If the client is uncomfortable and does not want to proceed, his or her reluctance should be respected. In some cases, there may be cultural reasons (i.e., a client has a collectivist cultural background) for refusing to do this activity.

8. Asset Flooding: With many teens who engage in challenging behaviors, communication breaks down because of how badly they are feeling about themselves. Consequently, communication and cooperation can be enhanced when the counselor simply stops and reflects on the teen’s positive qualities. Of course, you need to have several positive attributes available in your mind before beginning this intervention. You can proceed by saying something like: “You know, I was just thinking about how I think you have all sorts of good qualities. . . like you’re always on time, you hang in there and keep attending your classes, even though I know sometimes you don’t really like them. . . that tells me you’ve got courage, courage to face unpleasant things. . . I also like your sense of humor. . . and. . .”

9. Generating Behavioral Alternatives: Frequently teens become focused on one or two maladaptive behavioral responses to challenging situations. For example, they may either yell at their teacher or run out of class, but they seem unable or unwilling to try a more moderate response such as discussing their conflict or problem with the teacher in order to seek resolution. In the workshop, I will discuss a counseling session illustrating a modified behavioral alternatives procedure designed to reduce behavioral aggression.

10. Addressing Multicultural Differences: In the video clip with John and Michael, John begins by noting differences between the two of them and then asking Michael to share some of his personal experiences about being an African American gang member. This opening comes dangerously close to an inappropriate request – for Michael to educate John about his culture and lifestyle. However, because John emphasizes his interest in Michael’s personal experiences, the opening may be appropriate – but you can be the judge. After years of reflection, my (John’s) conclusion is that proactively addressing diversity issues is less genuine and may increase discomfort and decrease trust. It’s likely better practice to be genuine and genuinely respectful and then to address culture as it arises in the session . . . but I’m open to alternative ideas.

11. Noticing Process and Making Corrections: When there’s a clear pattern that begins to manifest itself in the counseling session, it’s best to acknowledge that pattern. This may be a pattern, as in the John-Michael clip, where the counselor is not “getting it” or having trouble accurately listening to the client. Or, it may be a situation where the counselor is trying to convince the student of something, but the student is resisting. In these situations, it’s recommended that the counselor acknowledge the process reality in the session.

12. Using Riddles and Games: In the Tough Kids book we describe a number of interesting activities that therapists can use with young clients. One strategy is to initiate some “mental set” activities with your client. For example, you might say, “I’d like you to say the word ‘ten’ ten times and I’ll count.” The client then says, “10, 10, 10. . .” and at the end you say, “Okay, what are aluminum cans made of?” Often the youth will say, “TIN” which of course the wrong answer, because the correct answer is aluminum. After doing this you can then discuss how our minds sometimes will misinterpret things which is why we should always think twice before reacting.

13. Cognitive Storytelling: Most teens, especially elementary teens, have a natural interest in stories and storytelling. In addition to using stories as metaphors, it can be useful for counselors to incorporate storytelling procedures that illustrate cognitive and behavior principles into counseling. The road rage, monkey surgery, or cherry story will be shared with participants in this workshop.

14. The Satanic Golden Rule: This technique is derived from Eva Feindler’s work with aggressive youth. It involves using the “Fool in the Ring” metaphor for helping youth see that they are giving up freedom when they react (predictably) and aggressively toward individuals who provoke them. The therapist draws a picture of two stick-figures engaging in a conflict and brainstorms how the young person being provoked might respond to conflict situations without engaging in retaliation and without engaging in behaviors likely to perpetuate aggression and result in negative consequences. Additionally, the message behind this metaphor and brainstorming activity is further developed by discussing the Satanic Golden Rule. In the end, youth are encouraged to use a more thoughtful and intentional response to provocation – instead of simply responding to aggression.

References

Bernstein, N. (1996). Treating the unmanageable adolescent. Northvale, NJ: Jason Aronson.
Castro-Blanco, D., & Karver, M. S. (2010). Elusive alliance: Treatment engagement strategies with high-risk adolescents. Washington, DC: American Psychological Association.
Creed, T. A., & Kendall, P. C. (2005). Therapist alliance-building behavior within a cognitive– behavioral treatment for anxiety in youth. Journal of Consulting and Clinical Psychology, 73, 498-505.
de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.
Feindler, E. (1986). Adolescent anger control. New York: Pergamon Press.
Glasser, W. (2002). Unhappy teens. New York: HarperCollins.
Hanna, F. J., Hanna, C. A., & Keys, S. G. (1999). Fifty strategies for counseling defiant, aggressive adolescents: Reaching, accepting, and relating. Journal of Counseling & Development, 77(4), 395-404.
Hawley, K. M., & Garland, A. F. (2008). Working alliance in adolescent outpatient therapy: Youth, parent and therapist reports and associations with therapy outcomes. Child & Youth Care Forum 37(2), 59-74
Kazdin, A. E. (2008). The Kazdin method for parenting the defiant child: With no pills, no therapy, no contest of wills. Boston, MA: Houghton Mifflin Company.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Preparing people for change (3rd ed.). New York: Guilford Press.
Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.
Sommers-Flanagan, J., & Bequette, T. (2013). The initial psychotherapy interview with adolescent clients. Journal of Contemporary Psychotherapy, 43(1), 13-22.
Sommers-Flanagan, J., Richardson, B.G., & Sommers-Flanagan, R. (2011). A multi-theoretical, developmental, and evidence-based approach for understanding and managing adolescent resistance to psychotherapy. Journal of Contemporary Psychotherapy, 41, 69-80.
Sommers-Flanagan, J., & Campbell, D.G. (2009). Psychotherapy and (or) medications for depression in youth? An evidence-based review with recommendations for treatment. Journal of Contemporary Psychotherapy, 32,111-120.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2007). Tough kids, cool counseling: User-friendly approaches with challenging youth (2nd ed.). Alexandria, VA: American Counseling Association.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2014). Clinical interviewing (5th ed.). Hoboken, NJ: John Wiley & Sons.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2012). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (2nd ed.). Hoboken, NJ: Wiley.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2004). The challenge of counseling teens: Counselor behaviors that reduce resistance and facilitate connection. [Videotape]. North Amherst, MA: Microtraining Associates.
Watkins, J. G. (1971). The affect bridge: A hypnoanalytic technique. International Journal of Clinical and Experimental Hypnosis, 19, 21-27.
Weisz, J., & Kazdin, A. E. (2010). Evidence-based psychotherapies for children and adolescents (2nd ed.). New York: Guilford.
Willock, B. (1986). Narcissistic vulnerability in the hyper-aggressive child: The disregarded (unloved, uncared-for) self. Psychoanalytic Psychology, 3, 59-80.
Willock, B. (1987). The devalued (unloved, repugnant) self: A second facet of narcissistic vulnerability in the aggressive, conduct-disordered child. Psychoanalytic Psychology, 4, 219-240.

If you have questions about this handout, or are interested in having John SF conduct a workshop or keynote for your organization, please contact John at: 406-243-4263 or john.sf@mso.umt.edu. You may reproduce this handout to share with your colleagues if you like, but please provide an appropriate citation. For additional free materials related to this workshop and other topics, go to John’s Blog at: johnsommersflanagan.com

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