Monthly Archives: July 2015

Counseling and Psychotherapy Theory and Practice, Tough Kids Cool Counseling

A Relationally-Oriented Evidence-Based Practice Model for Mental Health Counselors

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This paper is an adapted summary and extension of an article recently published in the Journal of Mental Health Counseling (April, 2015, pp. 95-108). The original article was titled: Evidence-Based Relationship Practice: Enhancing Counselor Competence. This abbreviation and adaptation is primarily designed to summarize the content, but also to focus more directly on the implications of developing an evidence-based model especially for mental health counselors. This paper ends with an “Appendix” outlining specific parameters of an evidence-based mental health counseling model. The Appendix material isn’t in the original article. If you’re a member of the American Mental Health Counseling Association, you can find the original article here: https://amhca.site-ym.com/?JMHCv37n2

Foundations

There are two domains that serve as a foundation for all competent mental health practice. These are:

1. Ethical practice
2. Multicultural sensitivity.

Professional counselors must practice ethically. At minimum, this means abiding by the ACA (2014) and American Mental Health Counselors Association (AMHCA; 2010) ethical codes. Ponton and Duba (2009) referred to this commitment as a covenant professional counselors have with and for their clients.

Traditional theoretical perspectives must be modified or expanded to address cultural diversity (J. Sommers-Flanagan, Hays, Gallardo, Poyralzi, Sue, & Sommers-Flanagan, 2009). Clients should not be expected to adapt to their counselor’s theory; rather, counselors should adapt their theory or approach to fit clients (Gallardo, 2013). Although multicultural competence is an ethical mandate, the need to embrace multicultural awareness, knowledge, and skills is also a practical reality. [The original article lists six evidence-based ways in which mental health counselors can adapt their counseling services to be more multiculturally sensitive.]

Evidence-Based Counselor Competence

Given the nature of professional counseling and counselor identity, it seems obvious that mental health counselors should embrace a model for counseling competence and EBP that emphasizes therapeutic relationships. That is why the model I propose considers both theoretically and empirically supported relationship factors and specific interventions (procedures). . . .

The reality is that relational acts and treatment methods are so closely interwoven that in counseling sometimes it is difficult to discern which is operating at a given moment (Lambert & Ogles, 2014). Consequently, the following Relationship-Oriented Evidence-Based Practice (ROEBP) behavioral descriptions incorporate both relational and technical components. The ROEBP behavior list primarily focuses on evidence-based relationship factors, although these relational factors are nearly always teamed with technical procedures.

Evidence-Based Relationship Factors

Each mental health counselor will inevitably display therapeutic relational factors in unique ways that may be difficult for other practitioners to replicate, because anything relational or interpersonal is alive, automatically unique, and therefore resists sterile descriptive language. Nevertheless, counselors can implement the following core relational attitudes and behaviors in their own unique manner and still adhere to EBP principles.

Congruence and Genuineness

In mental health counseling, the counselor is the instrument through which treatment is provided. This is probably why Rogers’s original core condition of congruence (1957) is still central to counseling efficacy. However, because Natalie Rogers (Sommers-Flanagan, 2007) once told me that she believed very few mental health professionals in the U.S. really understand her father’s work, let me make four brief points about congruence [You can read the original article to get the details on this].

The Working Alliance

In 1979, Bordin described the working alliance as a three-dimensional and pan-theoretical therapeutic factor. The three dimensions were (a) forming an emotional bond; (b) counselor-client goal-consensus or agreement; and (c) task collaboration. Researchers have affirmed that these working alliance dimensions contribute to positive treatment outcomes (Horvath, Re, Flückiger, and Symonds, 2011). [Practical ways in which mental health counselors can apply these three dimensions in their work are described in the article.]

Unconditional Positive Regard or Radical Acceptance

Originally, Rogers (1957) described unconditional positive regard as the counselor “experiencing a warm acceptance of each aspect of the client’s experience” (p. 98). This is, of course, often impossible. Though unconditional positive regard is easy and natural when counselor and client values are aligned, the competent counselor recognizes that there will be many discrepancies, small or large, between what the counselor thinks is right and what the client thinks is right. I recall a Pakistani Muslim supervisee who reported that hearing people talk about being gay or lesbian made her feel physically nauseated. To her credit, she worked through this (over a period of two years) and was able to embrace an accepting attitude. . . .

In addition to Rogers’s work, I’ve found Marsha Linehan’s dialectical behavior therapy concept of radical acceptance (1993) very helpful. As someone who has logged many counseling hours with clients who display challenging behaviors, remembering radical acceptance helps me greet even the most extreme and disagreeable (to me) client statements with a genuine accepting response (usually something like, “Thanks so much for sharing that with me and being so honest about what you think”).

Empathic Understanding

You should already be thoroughly familiar with Rogers’s ideas about empathy and the robust empirical support for empathy as a contributor to positive counseling outcomes. However, one important caveat about empathy is that the personal feelings of counselors and ratings of their own empathy are relatively unimportant. What matters is whether and how much clients experience their counselors as empathic. This is a crucial distinction. It is all too easy for all humans—including counselors—to focus on their side of interpersonal experiences. When it comes to whether empathy is a facilitative therapy condition, it is the client’s judgment of whether the counselor was empathic that predicts positive outcomes. . . .

Rupture and Repair

Getting it wrong is a natural part of life and counseling. There will always be empathic misses, poorly timed disclosures, and intermittent disengagement. These should be viewed as inevitable problems in the working alliance. As in many other areas of life, tension in the counselor-client relationship offers both danger and opportunity.

The danger is that counselors will ignore, overlook, or be unaware of relationship tensions or ruptures, in which case clients will be more likely to drop out of counseling and outcomes will be adversely affected. But the chance to correct our missteps is an unparalleled therapeutic opportunity. It involves the powerful process of self-correction and refocusing on the client and the counselor-client relationship. . . .

Although there are many ways to repair or work through relationship rupture, the original article discusses two overarching approaches.

Managing Countertransference

Thirty years ago Steve de Shazer (1984) not only reported that “resistance” had died as a therapeutic concept, he held a funeral for it in his backyard. Similarly, some counselors and psychotherapists might like to bury the whole idea of countertransference, putting it out of sight and out of mind. However, renaming or ignoring constructs will not make them go away.

Counselors are more effective when they are aware of and deal with their own unresolved emotional and behavioral reactions (Hayes, Gelso, & Hummel, 2011). Personal counseling or psychotherapy, clinical supervision, participation in peer supervision groups—such practices can help counselors become aware of and gracefully work through their countertransference reactions.

Implementing In- and Out-of-Session Procedures

Proponents of ESTs and EBP emphasize the importance of employing specific psychological or behavioral procedures with clients. Among the procedures that have empirical support are relaxation, exposure, behavioral activation, and problem-solving (Sommers-Flanagan & Sommers-Flanagan, 2012). In addition, some procedures, such as eye movement desensitization reprocessing (EMDR), have significant empirical support even though it is not clear whether the eye movements themselves or other parts of the tightly controlled EMDR protocol are the “active” ingredients. To be consistent with an evidence-based mental health counseling model, professional counselors should implement empirically supported procedures, but should do so using a collaborative interpersonal process. . . .

Progress Monitoring

Progress monitoring (PM) is a relatively new phenomenon on the evidence-based scene. PM is robustly related to positive outcomes and relatively easy to apply (Meier, 2015). Although not covered by many professional counseling publications, all practicing counselors should integrate some form of PM into their practice.

PM simply means that, formally or informally, counselors consistently check with clients about “how things are going.” Data from empirical studies consistently show, however, that practitioners who use formal progress monitoring rating scales tend to have both more favorable outcomes and fewer negative outcomes or treatment failures (Meier, , 2015). . . .

Concluding Comments

Mental health counselors can and should integrate evidence-based approaches into their practice. Although it might be useful for counselors to seek training in ESTs, embracing and applying evidence-based relationships as a core component of counselor competency is more consistent with professional counselor identity. The purpose of making this distinction and providing the information in this article is to advocate for an alternative evidence-based identity—one that counselors can more wholeheartedly embrace.

In this article I focused on nine relational factors that are empirically linked to positive counseling outcomes. This is only a beginning. Research will continue, and for space reasons I neglected several dimensions of counselor-client relational interactions that are consistent with professional counselor identity. For example, other than a brief discussion of PM, I did not address the potential merits and problems of formal assessment. In the future I would hope for a more distinct assessment model that specifies how counselors interact with clients, emphasizing transparency and collaboration. But that discussion must wait for another day. Until then, I wish you all the best as you incorporate relationally-oriented evidence-based counseling principles into the exceptionally important services you provide.

References are included in the original article

Appendix

[This is added material]

A General Practice Model for Evidence-Based Mental Health Counseling

Different professional groups use different terminology for describing their usual and customary standards for clinical practice. In psychology “empirically-supported” is often, but not always used as a means for identifying an approach that meets scientifically-based standards. Physicians and psychiatrists establish “practice parameters” for treating specific disorders. For example, the American Academy of Child and Adolescent Psychiatry (AACAP) has a Committee on Quality Issues that has generated practice parameters for depressive disorders, obsessive-compulsive disorders, multicultural competency, and many other areas of child and adolescent psychiatric clinical practice.

Given that psychology and medicine have their own language for referring to evidence-based standards, it might be useful for professional counseling to come up with its own terminology. This would be terminology that reflects an emphasis on achieving wellness (rather than the medical model) as well as the relational emphasis consistent with counseling. In the Journal of Mental Health Counseling article I referred to this as: Relationship-Oriented Evidence-Based Practice (ROEBP). This isn’t bad, but I’m guessing someone might be able to do better at capturing counselor identity within an evidence-based practice.

Here’s a first try at outlining an ROEBP for mental health counseling. I recognize that this is mostly a rough outline, but also believe that any practice guidelines that are established for professional mental health counselors should be broad so as to include many different and unique styles that exist among individual counselors.

1. All mental health counselors embrace their professional ethical guidelines and use multicultural sensitivity and appropriate multicultural adaptations when working with individual clients. These foundational competencies and commitments must be present for a professional counselor to claim he or she is practicing evidence-based mental health counseling.

2. Mental health counseling is initiated using a collaborative informed consent process. This process should include both written informed consent (consistent with HIPAA), but also verbal interactions to help make every specific counselors approach and style explicit to prospective clients.

3. When referral information is available to mental health counselors, at least some of this information is shared directly with clients using a positive and strength-based format and interaction.

4. Mental health counselors intentionally employ empirically-supported relationship factors throughout counseling. These include, but may not be limited to:

a. Having an office-setting and interpersonal demeanor that contributes to the development of a positive emotional bond between client and counselor

b. Developing a list of mutually agreed upon problems or goals that constitute the main focus of counseling. This involves a collaborative and empathic process.

c. Working with clients on in-session tasks or procedures that are explicitly linked to the mutually agreed upon counseling problems or goals.

d. Congruence and Genuineness

e. Unconditional Positive Regard or Radical Acceptance

f. Empathic Understanding

g. Managing Ruptures and Engaging in Repair

h. Managing Countertransference

5. Recognizing that clients are sometimes drawn toward and benefit from the application of specific therapeutic procedures, mental health counselors seek permission to use these procedures with clients if they are appropriate for the remediation of a particular problem and/or for client personal growth. The procedures employed should be empirically supported. If they are not empirically-supported (e.g., procedures from energy psychology) clients should be informed that the procedure may be promising, but is not a standard and accepted counseling procedure.

6. Mental health counselors use either a formal or informal progress monitoring procedure to consistently check with clients regarding the client’s perception of counseling progress.

Feel free to email me at john.sf@mso.umt.edu with comments about this article summary and ideas about evidence-based mental health counseling practice.

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Carl Rogers and Brain-Science do an Empathy Smackdown in Chapter 3

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Just because I know you all want in on the new introductory comments for Chapter 3 of the 6th edition of Clinical Interviewing.

And just because I’m wondering if my reference to Csikszentmihalyi’s fish cutter is too enigmatic.

Here’s the text; note it’s a draft with incomplete citations and likely grammar challenges.

Chapter 3

One vision for this chapter (and the next two) is to identify, describe, and illustrate every technical skill that therapists might employ during a clinical interview. We hope to do this so clearly that you can easily acquire and practice these skills. If we accomplish this vision, then you’ll know how to help clients:

• Talk openly about themselves, their problems, and their hopes;
• Have insights or new ideas about what they can do to manage their problems and achieve their personal goals; and
• Begin engaging in positive behavior change.

Other scholars and practitioners have referred to clinical interviewing technical skills as facilitative behaviors, helping skills, microskills, counseling behaviors, and more.

As we focus like a laser on skill-building, we also feel a troubling discomfort. This discomfort stems from our awareness that the great Carl Rogers would NOT AGREE IN THE LEAST with what we’re writing. Rogers would vehemently disagree because, for him, the special ingredients that make therapy work were NOT techniques or skills or behaviors. Instead, he repeatedly and emphatically claimed that successful therapy (even one-session clinical interviews) were all about therapist ATTITUDE—and the subsequent development of a “certain type of relationship” (Rogers, 1942, 1957, 1961; more on this in Chapter 6).

It’s always difficult to argue with Carl Rogers. His gentle, caring, and reflective voice keeps urging us to abandon skill development in the service of empathy training. And his point is exceptionally valuable, essential, and profound (we hope we’re making our thoughts on this clear). Many contemporary therapists, academics, and others don’t understand the essence of what Carl Rogers wrote and said about person-centered therapy. Too often his ideas are dumbed down to reflection skills (e.g., paraphrasing and reflection of feeling). The consequence of this dumbing down is that far too many helping professionals-in-training end up learning parroting skills. And we should note that parroting skills—unless emanating from an actual parrot and not a human counselor—are universally annoying and not particularly therapeutic.

As we open this chapter, we cannot in good conscience risk having you conclude that all you need to do is learn a couple dozen behavioral skills to become a good therapist or clinical interviewer. Rogers was right; that’s just not how it works.

Adopting a Therapeutic Attitude

Back in the 1940s, 50s, and 60s, Rogers repeatedly wrote about his core conditions or counselor attitudes. The conditions he viewed as necessary and sufficient to establish a therapeutic relationship were congruence, unconditional positive regard, and empathic understanding. If he were alive today, he would probably cringe at the modern emphasis on teaching therapeutic behaviors or skills, noting that nothing clinicians do can be therapeutic unless the clinician experiences and expresses the attitudes of congruence, unconditional positive regard, and empathic understanding. For the most part, research on counseling and psychotherapy has borne out his claims. As you’ll see, even contemporary neuroscience research is also broadly supportive of Rogers’s ideas.

Neurogenesis refers to the birth of neurons and is the biggest revelation in recent brain research. Although neurogenesis primarily occurs during pre-natal brain development, the so-called new brain research emphasizes adult neurogenesis; this is the discovery that humans can generate new neurons (brain cells) throughout the lifespan and not just during prenatal brain development). When adult neurogenesis happens, new neurons are integrated into existing neuro-circuitry.

From our perspective, the adult neurogenesis revelation is neither new nor particularly revelatory. For example, over 25 years ago, it was demonstrated that repeated tactile experiences produced functional reorganization in the primary somatosensory cortex of adult owl monkeys (Jenkins et al., 1990). This finding and subsequent research supporting neurogenesis essentially articulates a common sense principle that counselors and psychotherapists have utilized for decades. That is: Whatever behavior you rehearse, practice, or repeat, is likely to strengthen your skills in that area; and then, whatever skills you repeatedly practice will lead to you developing a brain that allows you to demonstrate these skills more efficiently. This is probably why Mihaly Csikszentmihalyi’s (1990) famous fish-cutter became able to experience optimal “flow” while fileting fish. It’s also how Carl Rogers became so adept at empathic understanding. For you, it’s the explanation and prescription for how you will become more like Carl Rogers than Csikszentmihalyi’s famous fish-cutter.

Research on the neuroscience of emotions is in its infancy. Consequently, you should take everything we write about it here (and that anyone writes about it anywhere) with a grain of salt. With that caveat in mind, let’s look at how modern brain science might support ideas for training yourself to be like Carl Rogers.

Researchers have recently been developing theories about what’s happening in different brain regions during an empathic experience. To summarize a large body of research, it appears that various brain regions and structures are especially activated when individuals have an empathic response. One particularly important brain structure involved in empathy experiences, self-regulation, and other behaviors linked to being helpful and compassionate is the insula.

More specifically, it appears that compassion meditation (aka lovingkindness meditation) is associated with neural activity and structural development (or strengthening) of the insula (or insular cortex). Researchers have reported that individuals who are highly experienced with compassion meditation have a thicker insula and that when they view or hear someone in distress they experience more neural activity in that brain region than individuals without much compassion meditation experience (Hölzel, Carmody, Vangel, Congleton, Yerramsetti, Gard, & Lazar, 2011). Other researchers have reported meta-analyses and other reviews indicating that during cognitive-emotional perception, regulation, and response, several brain structures are activated and the relationships among them are highly complex and integrated. In describing the role of the anterior insular cortex in empathic responding, Mutschler, Reinbold, Wankerl, Seifritz, and Ball (2013) wrote:

Accumulating evidence indicates a crucial role of the insular cortex in empathy: in particular the anterior insular cortex (AIC)—a brain region which is situated in the depth of the Sylvian fissure and anatomically highly interconnected to many other cortical regions (p. 1).

At the risk of oversimplifying a complex neurological process, it appears generally safe to conclude that compassion meditation and other human activities related to empathic experiencing may contribute in some way to the thickening of the insula and subsequently enhance empathic responsiveness.

Overall, at this early stage, it’s difficult for anyone to definitively declare how individuals can develop their brains to become more empathic. It’s tempting to conclude that, if you want to improve your empathic abilities, then you should engage in rigorous training to strengthen and grow your insula (and some of its empathy and self-regulation cohort like the middle cingulate cortex and pre-supplementary motor area; Kohn, Eickhoff, Scheller, Laird, Fox, and Habel, 2014). This brings to mind silly images of you engaging your insula in a series of cross-fit type workouts focusing particularly on its anterior muscular structure. Although the analogy and our knowledge about what’s really happening in the brain break down rather quickly, we nevertheless believe it makes sense for you to participate in a “training regime” that includes the following general steps:

1. Commit yourself to the intention of becoming a person who can listen to others in ways that are accepting, empathic, and respectful.

2. Similar to how meditators develop a meditation practice, develop an empathic listening practice. This could involve any form of regular interpersonal experience where you devote time to using the active listening skills described in this chapter. As you engage in this practice it is important to have listening with compassion as your primary goal.

3. Engage in the active listening, multicultural, and empathy development activities sprinkled throughout this text, offered in your classes, and that you obtain from additional outside readings.

4. When you watch television, read literature, and obtain information via technology, let yourself linger on and experience the emotions triggered during these normal daily activities.

5. Reflect on these experiences and then . . . repeat . . . repeat . . . and repeat some more.

Rogers wrote in very personal ways about his core conditions for counseling and psychotherapy. In the following lengthy quotation, he’s discussing obstacles that prevent most people from allowing themselves to step into another’s shoes and experience empathic understanding. Reading this excerpt (and following the preceding five steps and contemplating Multicultural Highlight 3.1) is part of our prescription for helping you adopt an empathic orientation toward individuals with whom you will work.

I come now to a central learning which has had a great deal of significance for me. I can state this learning as follows: I have found it of enormous value when I can permit myself to understand another person. The way in which I have worded this statement may seem strange to you. Is it necessary to permit oneself to understand another? I think that it is. Our first reaction to most of the statements which we hear from other people is an immediate evaluation or judgment, rather than an understanding of it. When someone expresses some feeling or attitude or belief, our tendency is, almost immediately, to feel “That’s right”; or “That’s stupid”; “That’s abnormal”; “That’s unreasonable”; “That’s incorrect”; “That’s not nice.” Very rarely do we permit ourselves to understand precisely what the meaning of his [or her] statement is to him [or her]. I believe this is because understanding is risky. If I let myself really understand another person, I might be changed by that understanding. (Rogers, 1961, p. 18; specific italics from the original are missing here)

All this makes me want to ask: How will you work to be more like Carl Rogers today?

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Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

What’s the Difference between the Clinical Interview and Full-On Counseling or Psychotherapy?

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I know my obsession with all things clinical interviewing is abnormal. This means I already know that most humans on the planet will have no interest in my hashing out the details and differences between clinical interviewing and psychotherapy. So, why then do I persist on blogging about such things? Well, the answer is simple: Obsessions are thoughts and compulsions are behaviors. Therefore, obsessions and compulsions go together like beans and rice. And so, as George Bush senior might have said, “It wouldn’t be prudent to not follow my clinical interviewing obsessions with a clinical interviewing behavior or two.” Now that I think of it, I’m certain that’s exactly what GWB I would have said, had he been asked about this very important situation.

There is, of course, the other reason. I’m revising (along with Rita) our Clinical Interviewing text to put it into the 6th edition. While doing so I have intermittent inspirations to post some of the new material we’re adding here and there. I think to myself . . . “this is the 6th edition of one of the most profound and exciting textbooks of all time and so I’m sure there might be 6 people out there who are interested in reading about what we’re writing.” Then again, as most of us know from either psychological research or common sense, it’s super-easy for me to fool myself into thinking other people are interested in whatever I’m interested in.

Now, having sufficiently fooled or rationalized or intellectualized or inspired myself . . . I present you with our latest thinking on clinical interviewing vs. counseling and psychotherapy.

Clinical interviewing vs. Counseling and Psychotherapy

Students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question and although it’s tempting to answer flatly, “There’s no difference whatsoever” the question deserves a more nuanced response.

The clinical interview is a remarkably flexible and ubiquitous interpersonal process. It’s designed to simultaneously initiate a therapeutic relationship, gather assessment information, and begin therapy. As such, it’s the entry point for clients (or patients) seeking mental health treatment, case management, or any form of counseling. Depending on setting, clinician discipline, theoretical orientation, and other factors, the clinical interview is also commonly known as the intake interview, the initial interview, the psychiatric interview, the diagnostic interview, the first contact or meeting, or any one of a number of other idiosyncratic and theoretically-driven names (Sommers-Flanagan, 2016, in press).

Although it includes therapeutic dimensions, the clinical interview is viewed primarily as an assessment procedure. This is one reason why clinical interviewing is typically included within the assessment portion of course curricula in counseling, psychology, psychiatry, psychiatric nursing, and social work. However, beginning with Constance Fischer’s work on Individualized Psychological Assessment and continuing with Stephen Finn’s articulation and development of therapeutic assessment, it’s also clear that, when done well, clinical assessment is or can be simultaneously therapeutic.

To make matters more complex, every attitude, technique, and strategy described in this text are also the attitudes, techniques, and strategies used in counseling and psychotherapy. Examples (along with their theoretical orientations) range from projective questions (psychoanalytic), therapeutic questions (solution-focused therapy), unconditional positive regard (person-centered), to psychoeducation (cognitive behavior therapy). Even further, some theoretical orientations ignore or de-emphasize assessment to such an extent that the traditional initial clinical assessment interview is transformed completely into an intervention (think solution-focused or narrative). In other cases, the clinical setting or client problem require that single therapy sessions involve an entire course of counseling or psychotherapy. For example,

“. . . in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish . . . an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.” (Sommers-Flanagan et al., 2015, p. 2)

From this perspective, not only is the clinical interview always the starting point for counseling, psychotherapy, and case management, it also may be the end-point. This is partly because many clients stop treatment after only one therapy session.

There may be other situations where an ordinary therapy session (if there is such a thing) can suddenly transform into a clinical assessment interview. The most common example of this involves suicide assessment interviewing (see Chapter 10). If and when clients begin talking about suicide ideation or exhibiting other suicide risk factors, the usual and customary standard of practice for all mental health and healthcare professionals is to smoothly shift the clinical focus from whatever was happening to a state-of-the-art suicide assessment.

All this leads us to the stunning conclusion: Everything that happens in a full course of counseling or psychotherapy may also occur within the context of a single clinical interview—and vice versa. Although it’s usually the starting point of counseling and psychotherapy, parts of a traditional clinical interview also occur during counseling and psychotherapy, regardless of theoretical orientation. The entire range of attitudes, techniques, and strategies you learn from this text constitute the foundation of skills you’ll need for conducting more advanced and theoretically specific counseling or psychotherapy.

R and J in Field