All posts by johnsommersflanagan

How to Make a Collaborative Plan for Terminating Counseling without Ever Using the Word Termination

Stone Smirk

Not long ago I noticed some of my excellent and well-intended supervisees talking with their clients about “termination.” They would say things like, “We need to prepare for termination” or “Let’s talk about termination today.” When this happened, I’d get nervous, squirm a bit, and eventually find a way to tell my supervisees that, although we use the word termination all the time when talking with each other ABOUT counseling, we shouldn’t use it when talking with clients DURING counseling.

Instead of saying termination, it’s preferable to talk about final sessions, or the ending of counseling, or to use normal and jargon-free words that speak to the reality that all good things—including counseling—must end. Sometimes the number of counseling sessions possible is dictated in advance by employee assistance program guidelines or insurance companies; other times, clients and counselors have more freedom to work together as long as the work is helpful or productive. Either way, ongoing conversations linking goals to progress is a part of an evidence-based approach to counseling and psychotherapy. Effective counselors connect the “ending” of counseling with the goals that were, in the beginning of counseling, collaboratively identified (and then possibly modified as needed).

Although you should use your own words, statements like some of the following can help you talk with clients or students about termination without using the word termination.

  • “Let’s talk about how our counseling is going and whether we’re making progress toward your goals”
  • “How do you feel about our counseling together?”
  • “I’d love to talk about what I can do differently to keep helping you move forward toward your goals.”

Speaking of termination—and now I’m speaking to you and not my clients—below you’ll find a Termination Checklist that you might find helpful as you talk with your students about preparing for termination. As will everything, this checklist is imperfect, but it’s a good start to help all of us address the ending of counseling, before counseling actually ends.

Termination Checklist

[Adapted from Sommers-Flanagan, J., and Sommers-Flanagan, R., (2007).
Tough Kids, Cool Counseling: User-Friendly Approaches with Challenging Youth.
Alexandria, VA: American Counseling Association]

This is a guide to help you think about termination—even though some of the details will be different for you and your client(s).

_____ 1. At the outset and throughout counseling, identify progress in the movement toward termination (e.g., “Before our meeting today, I noticed we have 4 more sessions left,” or “You are doing so well at home, at school, and with your friends. . . let’s talk about how much longer you’ll want or need to come for counseling”).

_____ 2. Reminisce about early sessions or the first time you and your client met. For example: “I remember something you said when we first met, you said: ‘there’s no way in hell I’m gonna talk with you about anything important.’ Remember that? I have it right here in my notes. You weren’t exactly excited about coming for counseling.”

_____ 3. Identify and describe positive behaviors, attitude, and/or emotional changes. This is part of the process of providing feedback regarding problem resolution and goal attainment: “I’ve noticed something about you that has changed. Do you mind if I share what I’ve noticed?” [Client gives permission]. It used to be that you wouldn’t let adults get close to you. And you wouldn’t accept compliments from adults. Now, from what you and your parents tell me and from how you act in here, it’s obvious that you give adults a chance. You don’t automatically push adults away from you. I think that’s a good thing.”

_____ 4. You should acknowledge, in advance, that the end of counseling is coming up, but there’s a possibility you’ll see each other in the future. “Our next session will be our last session. I guess there’s a chance we might see each other sometime, at the mall or somewhere. If we do see each other, I hope it’s okay for me to say hello. But I want you to know that I’ll wait for you to say hello first. And of course, if we see each other in public, I’ll never say anything about you having been in counseling.”

_____ 5. Identify a positive personal attribute that you noticed during counseling. This should be a personal characteristic separate from your client’s goals: “From the beginning of our time together, I’ve always enjoyed your sense of humor. You’re really creative and really funny, but you can be serious too. Thanks for letting me see both those sides. It took courage for you to get serious and tell me how you’ve been feeling about your mom.”

_____ 6. If there’s unfinished business (and there always will be) provide encouragement for continued work and personal growth: “Of course, your life isn’t perfect, but I have confidence that you’ll keep working on communicating well with your sister and those other things we’ve been talking about.” You may want to say that even though your client doesn’t “need” counseling, choosing to come back for counseling in the future might be helpful: “You know some people come to counseling to work on big problems; other people come because they find counseling helps them be a better person; and other people just like counseling. You might decide you want start up again for any of these reasons.”

_____ 7. Provide opportunities for feedback to you: “I’d like to hear from you. What did you think was most helpful about coming to counseling? What did you think was least helpful?” You can add to this any genuine statements about things you wish you’d done differently. For example, if your client got angry at you for misunderstanding something and this was processed earlier, you might say: “And of course I wish I had heard you correctly and understood you the first time around on that [issue], but I’m glad we were able to talk through it and keep working together.”

_____ 8. If it’s possible, let the client know that he or she may return for counseling in the future: “I hope you know you can come back for a meeting sometime in the future if you want or need to.”

_____ 9. Make a statement about your hope for the client’s positive future: “I’ll be thinking of you and hoping that things work out for the best. Of course, like I said in the beginning, I’m hoping you get what you want out of life, just as long as it’s legal and healthy.”

_____ 10. As needed, listen to and discuss how your client is feeling about ending counseling. Don’t make this into a big deal, but offer opportunities for the client to say “I can hardly wait for the end of this counseling crap” or “I wish we could keep meeting.” Whatever your client is feeling about termination warrants respectful listening.

_____ 11. Consider a parting gift. Although I don’t routinely recommend this with adults, with young clients you might give a meaningful gift at the end of counseling. It could be anything from a painted rock to a blank notebook for writing or a written card. The point is to give a gift that’s not especially expensive, but that might hold meaning for your client in the future.

For more information on termination with youth, go to: https://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly-ebook/dp/B00QYU630Q/ref=sr_1_7?s=books&ie=UTF8&qid=1550512844&sr=1-7&keywords=sommers-flanagan

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The End of Mental Illness, Part I

Irrigation Sunrise

For years I’ve planned to write a scintillating review of the words and phrases I now, as a wise and mature adult, refuse to use. The “c-word” (expelled in 1976) and “r-word,” (out forever in 1980), and “n-word” (never used) are notable, but they’re old and tired targets that most self-respecting people in the 21th century have also banished.

BTW, I got rid of tireless in 1988 (who doesn’t get tired, especially after the birth of a child, an all-nighter, or a long day’s work?). On a related note, I got rid of countless in the early 1980s, when, while studying statistics, it became obvious to me that everything was countable, unless you got too tired or too lazy to do the counting. But, even then it didn’t make much sense to just stop counting or to lose track and suddenly declare something countless. More than anything else, the word countless struck me as lazy. I would go with the lazy explanation for countless were it not for the fact that I also eliminated lazy from my vocabulary about 15 years ago when I read about Alfred Adler’s description of people who are lazy as not lazy, but instead people whose goals are beyond their reach and consequently, they experience discouragement (and not laziness).

More recently, I’ve grown weary of “the new brain-science” (how can it be that the media continues to refer to science from the 1990s as perpetually “new” but somehow the pleats in my pants have become so “old-fashioned” that I can no longer wear them in public?). On a related note, neurocounseling and neuropsychotherapy would be on my list for potential banishment, but because they’re new terms that people invented (along with polyvagal), purely for marketing purposes, they can’t be banished, because quite conveniently, I refuse to acknowledge their existence.

All this silly ranting about words makes me sound like a crank—even to myself. But as I get older, I find that worries over sounding like a crank are, in fact, more motivating than worrisome. Indeed, I’m embracing my intellectually snooty crankiness as evidence that I’m fully addressing the crisis inherent in Erik Erikson’s seventh psychosocial developmental stage: Generativity vs. Stagnation. Yes, that’s right, instead of stagnating, I’m cranking my generativity up to a level commensurate with my age.

In contrast to all these aforementioned banished or unacknowledged words, most people (who are otherwise reasonably intelligent) continue to use the term mental illness. As a consequence, the words mental illness have now risen to the coveted #1 spot on my billboard of eliminated words.

My preoccupation with avoiding term mental illness isn’t a news flash, as my University of Montana students would happily attest. For well over a decade, I’ve been explaining to students that I don’t use the term mental illness, and warn them, with what little roguish power I can muster, that perhaps when handing in their various papers throughout the semester, they also, at least for the time being and so as to not irritate their paper-grader, ought to follow my lead.

In my social life, whenever mental illness comes up in conversation, I like to cleverly state, “I never use the term mental illness unless I’m using it to explain why I never use the term mental illness.” This repartee typically piques the interest (or ire) of my conversational cohort, usually stimulating a question like, “Why don’t you ever use the term mental illness?”

“Wow. Thanks.” I say. “I thought you’d never ask.”

Three main cornerstones form the foundation for why I’ve made a solemn oath to stop privileging the words mental illness. But first, a tangential example.

This morning, once again, I’m awake at 3:30am, despite my plan to sleep until 7:00am. I know this awakening experience very well; I also know the label for this experience is insomnia, or, more specifically, terminal insomnia, or more casually known as, early morning awakening.

After this particular early morning awakening, I briefly engaged in meditative breathing until my thoughts crowded out the meditation. Having thoughts bubble up and crowd out meditative breathing is probably a common phenomenon, because neurotic thoughts, spiritual thoughts, existential thoughts, and nearly any thoughts at all, are nearly always far more interesting than meditative breathing.

A favorite statement among existentialists is that humans are meaning makers. As with many things existential, the appropriate response is something my teenage clients have modeled for me, “Well, duh.” Channeling my ever-present inner-teen, I want to respond to my inner-existentialist with a pithy retort like, “Yeah. Of course. Humans are meaning makers. Maybe we should talk about something even more obvious, like, we all die.”

What I find fascinating about the existential claim that humans are meaning makers is that existentialists always say it with gravity and amazement, as if being a meaning-maker is a profoundly good thing.

But, like life, meaning-making is not all good, and sometimes, not good at all. As I lay in bed along with my early morning awakening, it’s nearly impossible not to begin wondering about the meaning of the dream that woke me up (there was a broken anatomical bust of Henry David Thoreau in a small ocean-side creek at Arch Cape, Oregon); even more engaging however, is the so-called lived experience of terminal insomnia, and so my middle-of-the-night dream interpretation gets pushed aside for a more pressing question. “What’s the meaning of my regular waking in the middle of the night?” My brain, without consent, calls out this question, in an all-natural and completely unhelpful lived meaning-making experience. The explanations parade through my hippocampus: Could my awakening be purely physiological? Could it be that I missed my daily caffeine curfew by 30 minutes? Perhaps this is the natural consequence. But if so, why would I awaken now, after falling asleep as my head hit the pillow and sleeping for 4½ hours, instead of having a more easily explained experience of initial insomnia.

Of course, the most common explanation for early morning awakening is neurochemically filed in my brain and easily accessible. Without effort, I recall that terminal insomnia is a common symptom of clinical depression. I’ve known that for about 40 years. Now, by 3:45am, the various competing theories have completely crowded out my breathing meditation and will settle for nothing less than my full attention.

Is my terminal insomnia simply a product of the half-life of caffeine, or a full-bladder, or primary insomnia? Or is it something even more malignant, a biological indicator of clinical depression? Do I have a mental disorder? Although that might be the case, after briefly depressing myself with the contemplation of being depressed, I also begin refuting that hypothesis. My memory of taking an online “depression” test emerges, along with my score in the mild-to-moderate depression range. I might have believed the online questionnaire result, had it not been conveniently placed on the website of a pharmaceutical company and had it not culminated in the message, “Your score indicates you may be experiencing clinical depression. Check with your doctor. Lexapro may be right for you?”

Given that I’m absolutely certain that Lexapro isn’t right for me, the pattern analysis and search for deeper meaning breaks down here. I am a meaning-maker. I woke up at 3:30am. Now it’s 4am and I’m still awake. So what? It happens. When it does, I like to get up and write. It’s productive time. My stunning meaning-making conclusion is my usual conclusion: believing that I have a mental disorder is unproductive; in contrast, believing that I’m creatively inspired to write at 3:30am is vastly preferable and consistent with what Henry David Thoreau would want me to do in this moment.

What does all this have to do with eliminating the term mental illness from the human vocabulary?

Mental Illness Lacks a Suitable Professional Definition

Mental illness is a term without a professional or scientific foundation. Even the American Psychiatric Association doesn’t use mental illness in its latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The World Health Organization doesn’t use it either. I pointed out this fun fact while attending a public journalism lecture at the University of Montana. I asked the journalist-speaker why she used “mental illness” when the American Psychiatric Association and World Health Organization don’t use it. Initially taken aback, she quickly recovered, explaining that she and other journalists were trying to put mental health problems on par with physical health problems. That’s not a bad rationale. Mostly I want mental and physical health parity too, but what I don’t want is an assumption that all mental health problems are physical illnesses and therefore require medical treatments. Besides, whenever people make up (or embrace) non-professional and scientifically unfounded terminology to further their goals, their goals begin to seem more personal and political and less pure. In the end, I don’t think it’s right to make up words to negatively classify a group of fellow humans.

A side note: The American Psychiatric Association and World Health Organization are not left-leaning bleeding hearts; they would happily use mental illness if they felt it justified. Back in 2000, the authors of the 4th edition of the Diagnostic and Statistical Manual explained their reasoning:

The term “disorder” is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as “disease” and “illness.” “Disorder” is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here.

Broadly, my first reason for refusing to use the term mental illness is that it’s not used in the definitive publications that define mental disorders. It’s too broad and consequently, unhelpful. If mental illness isn’t good enough for the American Psychiatric Association and the World Health Organization, it’s not good enough for me.

Mental Illness is Too Judgmental

When asked about diverse sexualities, Pope Francis summarized my second reason for not using the term mental illness. He famously responded, “Who am I to judge?” I love this message and believe it’s a good guide for most things in life. Who am I (or anyone) to judge (or label) someone as having a mental illness?

You might answer this question by recognizing that I’m a mental health professional and therefore empowered to judge whether someone has a mental disorder; I’m empowered to apply specific mental disorder labels (after an adequate assessment). Sure, that’s all true. But I also have a duty to be helpful; although the communication of a diagnostic label might be helpful for professional discourse, insurance reimbursement, and scientific research, I don’t see how it’s helpful to categorize a whole group of individuals as “the mentally ill.” Hippocrates founded medical science. His first rule was “Do no harm.” As fun and entertaining as diagnosing other people and myself may be, I’ve come to the conclusion that doing so is often more harmful and limiting than good.

Think about it this way. Would it be any LESS helpful for us to delete the words “the mentally ill” and replace them with “people with mental health issues?” I think not. But you can decide what fits for you.

To the extent that it’s helpful to individual clients or patients, I’m perfectly fine with, after an adequate collaborative assessment process, diagnosing individuals with specific mental disorders. I believe that process, when done well, can help. What I’m against is using a broad-brush to label a large group of fellow humans in a way that can be used for oppression and marginalization. Why not just say that everyone has mental health problems and that some people have bigger and harder to deal with mental health problems. As Carl Jung used to say, “We’re all in the soup together.”

Mental Illness Resists De-stigmatization

Mental illness and its proxies, mental disease and brain disease, are inherently, deeply, and irretrievably stigmatizing. I know several different national and local organizations that are explicitly dedicated to de-stigmatizing mental illness. My problems with this is that the words mental illness are already so saturated with negative meaning that they resist de-stigmatization. The words mental illness instantly and systematically shrink the chance for therapeutic change and positive human transmorgrification.

If you look back in time, you’ll find that mental illness was created by people who typically have a political or personal interest in labeling and placing individuals into a less-than, worse-than, not-as-good-as, category. The terminology of brain disease and brain-disabling conditions are even worse. What I’m wishing for are kinder, gentler, and less stigmatizing words to describe the natural human struggle with psychological, emotional, and behavioral problems. If you’ve got some, please send them my way. I need help in my tireless efforts to let go of my crankiness and embrace hope, especially when I wake up in the middle of the night.

 

My Incredibly Insightful Comments on Self-Disclosure in Therapy from Counseling Today Magazine

Here’s a photo of me talking too much.

OLYMPUS DIGITAL CAMERA

Now imagine that I finally realize I’m talking too much, and to control myself, I place my hand over my mouth

***************************

Along with 10 other professionals, I was asked to write 300 words on using self-disclosure in counseling. All the comments were published this morning in the Counseling Today magazine.

I liked all the commentaries. You can read them here: https://ct.counseling.org/2019/01/counselor-self-disclosure-encouragement-or-impediment-to-client-growth/

But I was especially happy to see that three of the 11 selected professionals were linked to the University of Montana. Kim Parrow (doc student) and Sidney Shaw (former doc student) both provided their insights for the article. How cool is that?

Speaking of cool, and I know this isn’t appropriate, but I really liked my own commentary. I liked it partly because it sounds pretty smart and partly because I do a nice job of making fun of myself. And so here’s my short comment about self-disclosure in counseling:

My first thought about self-disclosure is that it’s a multidimensional, multipurpose and creative counselor response (or technique) that includes a fascinating dialectic. On one hand, self-disclosure should be intentional. If counselors aren’t aware that they’re using self-disclosure and why they’re using it, then they’re probably just chatting. On the other hand, self-disclosure should be a spontaneous interpersonal act.

Self-disclosure is an act that involves revealing oneself. As Carl Rogers would likely say, if your words aren’t honest and authentic, then your words aren’t therapeutic. From my perspective — which is mostly person-centered — the purest (but not only) purpose of self-disclosure is to deepen interpersonal connection. As multicultural experts have noted, self-disclosure can facilitate trust more effectively than a blank slate, because transparency helps clients know who you are and where you stand. What’s less often discussed is that it’s impossible to not self-disclose; we’re constantly disclosing who we are through our clothing, mannerisms, informed consent form, office accoutrements and questions.

I remember working with a 19-year-old white, cisgender, heterosexual male. He told me he was diagnosed as having reactive attachment disorder. After listening for 15 minutes, I was convinced that there was no possible way he could meet the diagnostic criteria for reactive attachment disorder. First, I used an Adlerian-inspired question/disclosure: “What if it turned out you didn’t really have reactive attachment disorder?”

You might not consider a question as self-disclosure, but every question you ask doesn’t simply inquire, it simultaneously reveals your interests.

Later, I disclosed directly, using immediacy: “As I sit and listen to all your positive relationships, it makes me think you don’t have reactive attachment disorder.” Despite my interpersonally clever use of an educational intervention embedded in a self-disclosure, my client didn’t budge, countering with, “That doesn’t make any sense, because I’m diagnosed with reactive attachment disorder.”

At that point, I wanted to use self-disclosure to share with him all the ways in which I was a smarter and better health care professional than whoever had originally misdiagnosed him. Fortunately, I experienced a flash of self-awareness. Instead of using disclosure to enhance my credibility, I spontaneously disclosed, “I’ve been talking way too much. I’m just going to put my hand over my mouth and listen to you for a while.”

As I put my hand over my mouth, my client smiled. The rest of the session was — in both our opinions — a rousing success.

 

Peggy Bit Me

Peggy Ellen (Sommers) Lotz was born on a cool, crisp day in Vancouver, Washington. The high temperature was 45 degrees. I know that because I read it in the Farmer’s Almanac. The date was January 28, 1955. That makes today her birthday. Happy Birthday Peggy!

Peggy is my older sister (but not the oldest; that distinction goes to Gayle, who will get her story later).

According to family legend, Peggy first introduced herself to me by biting my big toe. I was a newborn, my mother was holding me. Apparently, at age 2¾, Peggy didn’t appreciate me stealing all of our mother’s attention. I very much wish this incident had been video-recorded, not just for historical posterity, but also because I know it would go viral on the internet, just like the “Charlie bit me” video. Besides, if I had the video it would also mark the only time in recorded history that Peggy ever did anything mean toward anyone else.

I’ve long since forgiven Peggy for biting me. It was easy because of who she was, is, and always will be.

Throughout my childhood and teen years, Peggy would say terrible things to me like, “I’m busting with pride over you” and “I’m you’re biggest fan.” Seriously. And she meant it. I’ve read about this thing called sibling rivalry; I just never experienced it. There’s a famous psychologist named Alfred Adler who wrote about how children who are encouraged can do nearly anything. Peggy is the most flat-out encouraging person I’ve ever met. She helped me believe in myself. And that biting incident . . . well, knowing Peggy, I probably deserved it.

Peggy is pure of heart. From age 2¾—to whatever age she’s turning today—Peggy has acted toward others with kindness. Everything she does is laced with good intentions. Teach special education children. Check. Get your Master’s degree and become a school counselor. Check. Be a force for defending children from abuse. Check. Be a fantastic mom. Check. Return to the regular classroom and teach another decade because you love teaching and you love children and they love you. Check. Take care of our mother who needs caretaking. Check.

Growing up, our mom always said Peggy would become a social worker because she had empathy for everyone, took care of injured animals, and was naturally the most amiable person in our family, on our block, and maybe on the planet. If you need something, call Peggy.

Peggy is also smart and funny. Like most of us, she’s at her funniest when she’s not even trying. Take, for example, some profound “Peggy sayings.” My favorites are, “Nobody’s gonna pull the wool over my shoulders” and “You just gotta keep your shoulder to the grindstone.”

When you see her next, you might want to ask her if she has a thing about shoulders.

She also loves it when I tell the story of how surprised she was that they didn’t make her get a new driver’s license when she moved to Pullman to go to Washington State University. Be sure to ask about that too.

Peggy, today is your birthday. You being born was a happy day in the world.

I hope you know I’ve forgiven you for the biting thing. I also hope you know how much I admire you for who you are and the kindness you spread in the world. I hope you know that I know, you are a gift to me, our family, and so many more people.

And I hope you know I’m busting with pride over you, because, as you probably already know, nobody’s pulling any wool over my shoulders.

I love you Peggy. Have a fantastic birthday. You deserve it.

Guidelines for Using Congruence in Counseling and Psychotherapy

20160709_135123

Consistent with my recent preoccupation with evidence-based relationships in counseling and psychotherapy, I’m posting a short excerpt from the 6th edition of our Clinical Interviewing textbook (check it out here: https://www.amazon.com/gp/product/1119215587/ref=dbs_a_def_rwt_bibl_vppi_i0)

Here’s the excerpt, coming at you from Chapter 7: Evidence-Based Relationships.

Students often have questions about how congruence sounds and looks in a clinical interview. Common questions (and brief answers) follow:

  • Does congruence mean I say what I’m really thinking in the session? [Usually not. Your thoughts may mean something important and may warrant being shared at some point, but initial spontaneous thoughts and reactions to clients should stimulate personal reflection, not immediate disclosure.]
  • What if I dislike something a client says or does? Am I being incongruent if I don’t express my dislike? [No. If you have an aversion to something your client says or does, reflect on it, rather than reacting with judgment. As Rogers (1957) recommended, if you have a negative reaction, try to transform it to your internal experience and find a way to express it in a positive manner.]
  • If I feel sexually attracted to a client, should I be “congruent” and share my feelings? [Absolutely not. As discussed in Chapter 2, you should NEVER share feelings of sexual attraction with clients. Doing so is manipulative and unethical. Deal with your sexual issues and attractions in supervision and on your own time.]

One general guideline for determining when and how to be transparent or congruent is to ask: Would the disclosure help facilitate my client’s work?  Making this decision involves relying on your clinical judgment—which is difficult for everyone, but especially for new clinicians. Too much self-disclosure—even in the service of congruence or authenticity—can muddy the assessment or therapeutic focus. The key is to maintain balance; self-disclosure in the service of congruence should be limited, purposeful, and based on solid theoretical foundations (Ziv-Beiman, 2013)

Rogers (1958) was wary about excessive self-disclosure:

Certainly the aim is not for the therapist to express or talk about his (sic) own feelings, but primarily that he should not be deceiving the client as to himself. At times he may need to talk about some of his own feelings (either to the client, or to a colleague or superior) if they are standing in the way. (pp. 133–134)

Imagine that you’re working with a client and you feel the impulse to self-disclose in the spirit of being congruent. If you’re not confident your comment will be facilitative or will keep the focus on the client, then you shouldn’t disclose. Given the challenges inherent in deciding how to be congruent, you should discuss struggles with self-disclosure with peers or supervisors. This can deepen your understanding of how to be therapeutically congruent.

Based on recommendations from the literature (Farber, 2006; Kolden et al., 2011; Ziv-Beiman, 2013) and our own clinical experiences, we offer the following guidelines for self-disclosures:

  • Examine your motives for the self-disclosure you have in mind.Is it more about you or more about your client?
  • Ask yourself if the disclosure is likely to be facilitative.
  • Ask yourself if the comment will keep the focus on the client or will it distract from the client’s process and issues?
  • Consider the possibility of a negative reaction. Could your client respond in a negative or unpredictable manner?
  • Remember, congruence doesn’t mean you say whatever comes to mind; it means that when you do speak, you do so with honesty and integrity.

Case Example 7.1:

Congruence Across Cultures

Cultural identity has many dimensions (Collins, Arthur, & Wong-Wylie, 2010). In this example, during an initial clinical interview with an African American male teenager, the clinician uses congruence across several different cultural domains.

Client: This is stupid. What do you know about me and my life?

Clinician: I think you’re saying that we’re very different and I totally agree. As you can probably guess, I’ve never been in a gang or lived in a neighborhood like yours. And you can see that I’m not a Black teenager and so I don’t know much about you and what your life is like. But I’d like to know. And I’d like to be of help to you in some way during our time together.

This clinician is being open and congruent and speaking about obvious differences that might interfere with the clinician-client relationship. It would be nice to claim that being open like this always improves clinician-client connection, but nothing always works. However, as researchers have reported, congruence tends to facilitate improved treatment process and also contributes to positive outcomes, at least in small ways (Kolden et al., 2011; Tao, Owen, Pace, & Imel, 2015).

Top Blogs for 2018

JSF Dance Party

Reviewing the past is a bit easier than predicting the future; so despite my love predicting what will happen tomorrow, today’s blog is about yesterday.

Last year was rough. Nearly everyone agrees on that, although I suspect that finding consensus on who to blame for last year’s roughness would make fodder for unpleasant argument rather than agreement.

In the midst of all this disagreement, I decided to see which of my blogs garnered the most interest. That’s sort of like picking out blog posts that were agreeable reads.

I recognize that this info might only be of interest to me. Then again, this is a blog and blogs are traditionally about whatever interests the blogger. Sorry about that. There’s no peer review. Apparently I submitted this post to myself and it passed my rigorous editorial review.

First, a look way back to late 2011 when this blog started with what one of my favorite topics: the amazing Mary Cover Jones. https://johnsommersflanagan.com/2011/11/25/a-black-friday-tribute-to-mary-cover-jones-and-her-evidence-based-cookies/

Back then, in 2011, I had a total of 1,522 blog “hits” with the top blog being a very short “26 Years with Rita” message. https://johnsommersflanagan.com/2011/12/30/26-years-with-rita/

In 2012, the first full year of JSF blogging, there were 15,486 hits, with the favorite new 1,167 hit post being “Two Sample Mental Status Examination Reports.”

Fast forward to 2018. Overall there were 156,811 hits, with the hottest post–by a landslide with 62,647 hits being. . . drum roll: “Two Sample Mental Status Examination Reports.”  https://johnsommersflanagan.com/2012/08/10/two-sample-mental-status-examination-reports/

The second most popular post of 2018 was:

The wildly popular 2015 post (with 14, five star likes) “Constructive vs. Social Constructionism: What’s the Difference?” and 11,691 hits. https://johnsommersflanagan.com/2015/12/05/constructivism-vs-social-constructionism-whats-the-difference/

The top three new posts from 2018 were:

#1: “Bad News in Threes” https://johnsommersflanagan.com/2018/06/08/bad-news-in-threes-kate-spade-anthony-bourdain-and-the-cdc-suicide-report/

#2: “The Diagnostic Clinical Interview” https://johnsommersflanagan.com/2018/02/27/the-diagnostic-clinical-interview-tips-and-strategies/

#3: “New Journal Article” https://johnsommersflanagan.com/2018/03/09/new-journal-article-conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/

Okay. That’s enough self-reflection. Soon and next, I’ll be posting my 2018 New Year’s resolution. Here’s to hoping that happens soon.

And for now, before we run out of January. . .

Happy New Year!

 

 

Transforming Therapeutic Relationships into Evidence-Based Practice

img_1349This handout is an in-depth supplement to a web-based workshop I provided for the Chi Sigma Iota group at the University of the Cumberlands on January 13, 2019. Although it’s designed to go with the workshop, it’s also designed to be a standalone resource for learning more about how to integrate evidence-based relationship factors into counseling and psychotherapy practice.

The following principles, techniques, and strategies are listed in the order in which they were discussed in the workshop. More extensive information is included in the specific resources listed at the end of this handout, particularly, Clinical Interviewing (6th ed., Wiley 2017), Counseling and Psychotherapy Theories in Context and Practice (3rd ed., Wiley, 2018) and Tough Kids, Cool Counseling (2nd ed., 2007, ACA publications).

The 10 Evidence-Based Relationship Factors (EBRFs)

Beginning in the early 21st century, Norcross (2001; 2011) and others have put relational factors (e.g., Rogerian core conditions) on par with “empirically-supported techniques or procedures.” Norcross has done this by using the terminology: Evidence-Based or Empirically-Supported Relationships

What Norcross is talking about is the robust empirical support for specific and measurable relationship factors as contributors to positive counseling and psychotherapy outcomes. You can find the latest articles about empirically-supported relationships in a special issue of the journal Psychotherapy (Norcross & Lambert, 2018).

Here’s a list of the evidence-based relationship factors (EBRFs) that I covered in the workshop, followed by content and resources related to each factor.

  1. Congruence [Authenticity]
  2. Unconditional positive regard [Respect]
  3. Empathic understanding [Emotional attunement]
  4. Culture Humility and Sensitivity [Equity in worldview]
  5. Working Alliance 1: Emotional bond [Liking each other]
  6. Working Alliance 2: Goal consensus [Adler’s goal alignment]
  7. Working Alliance 3: Task collaboration [To reach client goals]
  8. Rupture and repair [Fixing relationship tension]
  9. Managing Countertransference [Self-awareness]
  10. Progress monitoring [Asking for feedback]

1. Congruence/Authenticity

There are many ways to show congruence or authenticity in counseling. Below, I’ve described some of the ways that are relatively easy to apply. Some of this content focuses on working with youth and other content focuses on working with adults, including parents.

Acknowledging Reality: Some young people, as well as older clients, may be initially suspicious and mistrustful of adults – especially sneaky, manipulative, authority figures like mental health professionals, school counselors or school psychologistsJ. To decrease distrust, it’s important to acknowledge reality about the reasons for meeting, about the fact that you don’t know each other, and to notice obvious differences between yourself and the client. Acknowledging reality is a form of transparency or congruence. Researchers consistently report that transparency, congruence, or genuineness is a predictor of positive counseling or psychotherapy outcomes (see Kolden, Klein, Wang, & Austin, 2011). Acknowledging reality includes a straightforward explanation of confidentiality and its limits.

Sharing Referral Information: To gracefully talk about referral information with students, you need to educate referral sources about how you’ll be using information they share with you. Teachers, administrators, probation officers, and parents should be coached to give you information that’s accurate and positive. If the referral information is especially negative, you should screen and interpret the information so it’s not overwhelming or off-putting to students. Simblett (1997) suggested that if therapists are planning to share referral information with clients, they should warn and prepare referral sources. If not, the referral sources may feel betrayed. Also, if you share negative referral information, it’s important to have empathy and side with the student’s feelings, while at the same time, not endorsing negative behaviors. For example, “I can see you’re really mad about your teacher telling me all this stuff about you. I don’t blame you for being mad. I’d be upset too. It’s hard to have people talking about you, even if they have good intentions.” Here’s a case example from Tough Kids, Cool Counseling (2007):

 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. (from Sommers-Flanagan and Sommers-Flanagan, 2007, p. 32) 

 Authentic Purpose Statements: One technical manifestation of congruence or transparency is the use of an authentic purpose statement. This requires you to be clear about your own “why” of being in the room and then concisely sharing that with your student or client. Examples include: “My job is to help you be successful here” or “Your goals are my goals, as long as they’re legal and healthy.” Authentic purpose statements can also serve, in part, as an initial role induction.

 Responding to Client or Student Questions: Authenticity may be the most robust factor linked to positive treatment outcomes. How you handle client or student questions is one way to display congruence or authenticity. The following model can be helpful.

  1. Answer directly or explain why you’re not answering directly – “I think you’re asking a good question, but before I answer, I want to dive a little deeper into what’s under your question. That’s the sort of thing we do in counseling.”
  2. Use a reflection/paraphrase – “It sounds like you’re not sure I can be of any help.”
  3. Validate the underlying message/curiosity – “I don’t blame you for thinking that. Lots of people aren’t sure if counseling can work for them. I’d probably feel the same way as you.”
  4. Use psychoeducation, then answer after exploring – “Before answering, I’d like to ask you a few questions that might be important. First, if I say, ‘Yes’ I’ve done some drugs, I wonder how you would react? Second, if I say ‘No’ I haven’t done drugs, I wonder how you would react to that?”
  5. Use psychoeducation to explain not answering – Most of the time I’m happy to answer your questions. But this one feels like it’s too much about me . . . and of course the focus in counseling is supposed to be more on you than it is on me.”
  6. Use interpretation or confrontation – “It’s not unusual in counseling for clients to want to avoid talking about their personal situation and feelings. One way to avoid that is to ask me lots of questions. I’m wondering if that might be one of the reasons why you seem like you want to keep the focus on me.”
  7. Articulate a dilemma (Yalom) – “I have a dilemma. One part of me really wants to answer your question. But another part of me is worried it will move the focus of counseling away from you and onto me.”

 Self-Disclosure: Although authenticity is important, it’s quite possible to be too open or to have too much self-disclosure. To prevent excessive self-disclosure, consider the following guidelines.

 When to Self-Disclose

  • When you’re asked a direct question and it makes good sense to answer directly and briefly.
  • When a disclosure is likely to increase interpersonal connection (“I enjoy meeting with you”).
  • When disclosure is likely to facilitate transparency and therefore make it less likely for clients to “wonder” if you’re judging them (“my theoretical foundation is person-centered. That means I want to listen to you talk about your life, your experiences, and your emotions. That means I’ll probably listen more than I talk”).
  • When it’s helpful for psychoeducation purposes (mindfulness takes lots of discipline; I struggle with it too.” If you’re interested, I can share with you a couple tips that really helped me”)

 When NOT to Self-Disclose

  • When you’re talking too much about yourself and muddying the focus.
  • When you’re trying to slip in advice (e.g., “being assertive in that sort of situation worked for me”). This is especially a bad idea with minority clients because we shouldn’t assume they have our values or that what worked for us will work for them.
  • When it takes away from any of the EBRFs.
  • When it’s more about you and for you and less about the client (“I’m really proud of my children’s work ethic”).

2. Unconditional Positive Regard

Unconditional positive regard involves accepting clients and showing them immense respect. As Rogers said long ago, when clients feel accepted, then they become free to explore their insecure “nooks and crannies.”

For all of the person-centered core conditions, it’s not good to express them directly. That means you want to avoid saying “I accept you fully as you are.” There are many reasons for not expressing the core conditions directly (which we talk about in the book, Clinical Interviewing). The following counselor/psychotherapist behaviors are ways to show respect and positive regard indirectly. I’ve elaborated on a few of these.

  • Being on time
  • Non-directive listening
  • Asking clients what is important to them
  • Remembering client details
  • Asking permission
  • Second session first question
  • Using interactive summaries

 Asking Permission: Asking permission is a basic technique that clearly expresses your respect for your client. When using any technique, it’s useful to (a) ask permission to describe the technique (“Is it okay if we take a few minutes for me to describe this thing called progressive muscle relaxation?”); (b) describe the technique; and then (c) check in on your client’s reaction or thoughts about the technique. I even like to ask permission to self-disclose or give feedback (“Is it okay with you to share something I’ve noticed?”).

 Second Session First Question: The time between session #1 and session #2 can include many different experiences. It’s tempting to start the second session with a social question like, “How was your week?” My opinion is that social openings tend to defocus counseling and mostly aren’t appropriate (unless you’re modeling social skills and/or have an anxious client who is uncomfortable with a more formal opening. The second session first question is: “What did you find memorable or important to you from our meeting last week?”

 3. Empathic Understanding

 Most counselors and counseling students are well-versed in how to use empathy. One situation that can challenge your empathic responding occurs when you’re working with a client who is depressed and suicidal. The following is an adapted excerpt from an article published in the Journal of Health Service Psychology:

 Many or most suicidal patients are probably experiencing depression and/or hopelessness. If this is the case, they will be predisposed to discussing what makes them more suicidal; it may be more difficult for them to identify factors linked to feeling less suicidal. States of depression and hopelessness drive patients toward negative rumination and act as fogging agents when it comes to exploring or considering positives.

Exploring and Addressing Hopelessness

Hopelessness is a common feature linked to clinical depression and suicidality. Although hopelessness can manifest in different ways, having a general strategy for assessing and working through hopelessness can be helpful. Specifically, Beck (Wenzel, Brown, & Beck, 2009) has emphasized that treatment of suicidal patients must address hopelessness. Here are two examples of how to empathically explore and work with hopelessness.

Exploring intent, addressing hopelessness, and initiating problem-solving in the context of getting help. Once you have information about active suicide ideation or a previous attempt or attempts, you have a responsibility to acknowledge and explore suicidality. One common strength-based tool is a solution-focused question.

“You’ve tried suicide before, but you’re here with me now . . . what has helped?”

Unfortunately, if you’re working with a patient who is severely depressed, it is not unusual for your solution focused question to elicit a response like this:

“Nothing helped. Nothing ever helps.”

In response, one error clinicians often make is to venture into a yes-no questioning process about what might help or what might have helped in the past. However, if you are working with a patient who is extremely depressed and experiencing mental constriction, your patient will discount every idea you come up with and insist that nothing ever has helped and that nothing ever will help. This process can increase hopelessness and consequently a different assessment approach is required. Even the most severely depressed patients can, when given the right frame, acknowledge that every attempt to address depression and suicidality isn’t equally bad. Using a continuum where severely depressed and mentally constricted patients can rank interventions strategies (instead of a series of yes-no questions) is a better approach:

Counselor: It sounds like you’ve tried many different things to help with your depressed feelings and suicidal thoughts. Let’s look at all them. I’m guessing some of them are worse than others. For example, I know you’ve tried physical exercise, you’ve tried talking to your brother and sister and one friend, and you’ve tried different medications. Let’s list these out and see which has been worse and which has been less bad.

Client: The meds were the worst. They made me feel like I was already dead inside.

Counselor: Okay. Let’s put meds down as the worst option you’ve experienced so far. Which one was a little less worse than the meds?

You’ll notice the counselor emphasized that some efforts at dealing with depression/suicide were worse than others. Focusing on “worse” resonates with the patient’s negative emotional state. It will be easier to begin with the most worthless strategy of all and build up to strategies that are “a little less bad.” Building a unique continuum of helpfulness for your patient is the goal. Then, you can add new ideas that you suggest or that the patient suggests and put them in their appropriate place on the continuum. If this approach works well, you will have collaboratively generated several ideas (some new and some old) that are worth experimenting with in the future.

Addressing hopelessness and initiating problem-solving in the context of social disconnection. As you explore Susan’s social relationships, you ask, “Who is in your life that might provide you with support during this difficult time?” She answers, “I just don’t get on with people. No one understands. There’s no point talking to anyone.” With this disclosure, Susan has revealed interpersonal disconnection, along with hopelessness about being socially disconnected forever. At this point, it’s easy for clinicians to fall into an unproductive problem-solving pursuit in an effort to identify someone in Susan’s environment who would show her kindness and compassion (e.g., “How about your mother?”). Instead, because Susan is experiencing depressive symptoms, one way in which she might display problem-solving impairment is by denying that anyone in her world could be helpful. Consequently, the problem-solving process should begin with the counselor resonating with Susan’s hopelessness, and then move forward. Here’s an illustration:

Counselor: It feels like there’s no one to turn to. Nobody really gets what you’re going through.

Susan: That’s the way it has always been.

Counselor: This might sound weird, but I’m wondering who is the worst person for you to talk with? Who would really not get it and just make you feel worse?

Susan: That’s easy. My dad doesn’t get me. He would tell me I need a kick in the ass to get myself going.

Counselor: And that would feel really not helpful. Not helpful at all.

Susan: That’s never helpful to me.

Counselor: How about someone who’s not quite as bad as your dad? Who would be a little better than him, but still not especially good to talk with?

You can also use a visual version of this approach. To do so, you draw a circle in the middle of the page and write your patient’s name in the circle. Then, you say you want to get a visual sense of who, in the patient’s universe of social contacts, is most and least likely to be responsive and show support. In Susan’s case, you would place her father as a very distant circle in orbit around Susan. Then as you generate additional names, you would follow Susan’s guidance and place the circles closer or further away from the circle representing Susan. In the end, you will have a map of who—in Susan’s social universe—is closest (and furthest) and most (and least) supportive.

With patients who are depressed and experiencing problem-solving deficits, a good general strategy is to show empathy for the hopelessness and social disconnection, but then build a continuum from the bottom toward people who are “less bad” to talk with.

This method: (a) provides empathy; (b) addresses hopelessness; (c) addresses problem-solving deficits through the identification of alternative social support people; and (d) initiates problem-solving (by building a continuum that moves upward toward the best or “least bad” people for social connection).

4. Culture and Cultural Humility

Competent counselors and psychotherapists are able to reach across cultural divides with respect and sensitivity. In preliminary research, cultural humility has been linked with positive therapeutic outcomes.

Here’s a short excerpt on cultural humility from the Clinical Interviewing textbook:

Over the past decade researchers and writers have begun making distinctions between cultural competence and cultural humility. Cultural humility is viewed as an overarching multicultural orientation or perspective that mental health providers may or may not hold. It springs from the idea that individuals from dominant cultures—or any culture—often have a natural tendency to view their cultural perspective as right and good and sometimes as superior. This tendency implies that attaining multicultural competence isn’t enough for clinicians to be effective with culturally diverse clients. Clinicians need to be able to let go of their own cultural perspective and value the different perspective of their clients (Hook, Davis, Owen, Worthington, & Utsey, 2013).

Three interpersonal dimensions of multicultural humility have been identified:

  1. An other-orientation instead of a self-orientation
  2. Respect for others and their values/ways of being
  3. An attitude that includes a lack of superiority

 Cultural humility is closely aligned with, but not the same thing as multicultural competence. It’s generally presented as a supplement to multicultural competence. It has its own research base and appears to independently contribute to clinician effectiveness. In a recent research study, when clients viewed therapists as having higher levels of cultural humility, they also (a) endorsed higher ratings of the working alliance and (b) perceived themselves as having better outcomes (Hook et al, 2013).

 The Working Alliance

 Clinical research on the working alliance is immense. The section below is another excerpt from Clinical Interviewing.

The idea that therapist and client collaborate in ways that support positive outcomes originated with Freud (1912/1958). Later, psychoanalytic theorists introduced the terms therapeutic alliance and working alliance (Greenson, 1965; Zetzel, 1956). Greenson (1965, 1967) distinguished between the two, viewing the working alliance as the client’s ability to cooperate with the analyst on psychoanalytic tasks and the therapeutic alliance as the bond between client and analyst. Eventually, Bordin (1979; 1994) introduced a pantheoretical model that he referred to as the working alliance. Bordin’s model includes three dimensions:

  1. Goal consensus or agreement
  2. Collaborative engagement in mutual tasks
  3. Development of a relational bond

 5. Goal Consensus (Mutual Goal-Setting)

 Goal-Setting with Young Clients: I use the following procedure for setting mutual goals with young clients. This technique is used to help students or young clients begin to articulate their own goals (and not goals that have been defined FOR THEM by adults).

Working with adolescents is different from working with adults. In this excerpt from a 2013 article, we briefly focus on how the opening interaction with an adolescent client might look different than an opening interaction with an adult client (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.

 Wishes and Goals: Wishes and goals is a specific mutual goal-setting procedure that I’ve used with youth. It’s described in the Tough Kids, Cool Counseling book. You can watch a youtube video demonstration of the procedure being used as part of a session opening with a 12-year-old client named Claire. Here’s the link: https://www.youtube.com/watch?v=rHHrMC8t6vY&feature=youtu.be

 6. Collaborative Therapeutic Tasks (aka task collaboration)

 In psychotherapy, tasks and techniques are also referred to as procedures. Even if counselors are employing a highly relational approach, it is still crucial to engage clients in specific tasks, activities, or procedures that are conceptually linked to solving their problems and achieving their goals. This may be a more implicit process, as when a solution-focused counselor helps clients identify and elaborate on exceptions, or more explicit, as when counselors teach clients how to make decisions using a four-step problem-solving process.

 Though engaging clients in therapeutic tasks involves applying specific techniques, it quickly becomes relational. From the evidence-based relationship perspective, which specific procedures to apply is far less important than how they are applied. They must be applied collaboratively:

  1.  The procedure—such as progressive muscle relaxation, Socratic questioning, or eye movements—must be explained clearly and linked to client goals (a psychoeducation process).
  2.  Before the procedure is employed in the session, the client gives explicit permission or informed consent (e.g., “Is it okay with you if we try out this progressive muscle relaxation technique?”). This permission-seeking interaction is sometimes referred to as an invitation for collaboration.
  3.  This part of the relational piece is crucial: after implementing the task or procedure, evidence-based counselors intermittently check in with clients (e.g., “What was your reaction to the role play we just tried?”). This requires sensitivity, empathic listening skills, and reassurance. Again, it makes no difference whether the specific task or procedure is free association (psychoanalytic theory), active listening and encouragement of the emergence of the self (as in person-centered counseling), reflecting as-if (Adlerian counseling), mindfulness meditation (cognitive-based mindfulness therapy), or another option. The point is that the relational activity of working together on a task contributes to positive outcomes (the preceding is from Sommers-Flanagan, 2015).

 7. Forming an Emotional Bond

A good example of a positive emotional bond occurs when counselors and clients experience mutual liking and mutual positive anticipation of counseling sessions. The following excerpt is from Sommers-Flanagan (2015).

The formation of a positive emotional bond begins with informed consent, continues in the waiting room and during first impressions, includes creation of a pleasant and comfortable counseling space, and involves specific counselor responses throughout each session, such as empathic reflections, positive strength-based feedback, and validating feelings. It also involves letting clients talk about their problems and the past as they wish—even when the counselor is operating from an approach that typically does not place much value on gathering historical information, such as CBT or solution-focused counseling. For example, Judith Beck (2011) emphasized that cognitive-behavior therapists should talk freely with clients about the past either when the client is stuck or when clients want to talk about the past. This is one of the ways in which relational and technical aspects of counseling merge. For all theoretical perspectives—from existential to reality therapy to CBT—counselors take special care to bond with clients, and part of that bonding involves letting them talk about what they want to talk about.

 Recommendations for Developing a Positive Working Alliance

 Again, from Clinical Interviewing.

Therapists who want to develop a positive working alliance (and that should include everyone) will employ alliance-building strategies beginning with first contact. Using Bordin’s (1979) model, alliance-building strategies focus on (a) collaborative goal setting; (b) engaging clients in mutual therapy-related tasks; and (c) development of a positive emotional bond. Progress monitoring is also recommended. The following list includes alliance-building concepts and illustrations:

Initial interviews and early sessions are especially important to alliance-building. Many clients will be naïve about psychotherapy. This makes role inductions essential. Here’s a cognitive-behavioral therapy (CBT) example:

For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)

Asking clients direct questions about what they want from counseling and then integrating that information into your treatment plan helps build the alliance. In CBT this includes making a problem list (J. Beck, 2011).

Clinician:     What brings you to counseling and how can I be of help?

Client:          I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.

Clinician:     Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we say, “Find ways to help you start feeling more up?”

Client:          Sounds good to me.

Engaging in collaborative goal-setting to achieve goal consensus is central to alliance-building. In CBT this involves transforming the “problem list” into a set of mutual treatment goals.

Clinician:     So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?

Client:          Totally. It would be amazing to tackle those successfully.

Problem lists and goals are a good start, but clients engage with clinicians better when they know the treatment plan (TP) for moving from problems to goals. The TP includes specific tasks that will happen in therapy and may begin in the first clinical interview. Here’s an example of a “Devil’s Advocacy” technique where the clinician takes on the client’s negative thoughts and then has the client respond (Newman, 2013). You’ll notice that collaboratively engaging in mutual tasks offers spontaneous opportunities for deeper connection and clinician-client bonding:

Clinician:     You said you want a romantic relationship, but then you start thinking it’s too painful and pointless. Let’s try a technique where I take on your negative thinking and you respond with a reasonable counter argument. Would you try this with me?

Client:          Sure. I can try.

Clinician:     Excellent. Here we go: “It’s pointless to pursue a romantic relationship because they always come to a painful end.”

Client:          That’s possible, but it’s also possible to have some good times along the way toward the painful end.

Clinician:     [Smiles, breaks from role, and says] . . . That’s the best come-back ever.

Soliciting feedback from clients from the first session on to monitor the quality and direction of the working alliance contributes to the alliance. Although you can use an instrument for this, you can also ask directly:

We’ve been talking for 20 minutes and so I want to check in with you on how you’re feeling about our time together so far. How are you doing with this process?

Making sure you’re able to respond to client anger without becoming defensive or counterattacking is essential to positive working relationships. We usually apply radical acceptance (Linehan, 1993). Here’s an excerpt from an initial session with an 18-year-old male where the clinician accepted the client’s aggressive message and transformed it into a relational issue:

Clinician:     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) (J. Sommers-Flanagan & Bequette, 2013, p. 15).

Clinician:     Thanks for telling me that. I’d never want to have the kind of relationship with you where you felt like hitting me. And so if I ever say anything that offensive, I hope you’ll just tell me, and I’ll stop.

 8. Rupture and Repair

In many counseling situations there are inevitable strains, impasses, resistance, and intermittent weakening of the therapeutic relationship. These things happen naturally and both client and the counselor contribute to these therapeutic ruptures. As counselors, sooner or later, we all  “fail” to get it right; we might miss with our paraphrases, let out a little judgment, or recommend a therapeutic task that the client finds aversive.

There are two basic signs of therapeutic rupture. These include (a) when clients withdraw and (b) when clients behave in an aggressive or confrontational manner.

If/when you notice there may be a rupture, you have several options. These include:

  • Apologizing
  • Repeating the therapeutic rationale
  • Changing tasks or goals
  • Clarifying misunderstandings at a surface level
  • Exploring relational themes and taking responsibility for the rupture (this might include cultural misunderstandings)

Of course, repair doesn’t happen instantly, but over time, you can regain trust and deepen the relationship.

 Noticing Process and Making Corrections (Rupture and Repair): When there’s a clear pattern that begins to manifest itself in the counseling session, it’s best to acknowledge that pattern. In one session I had with a Black 19-year-old male, I offered a half-dozen paraphrases and most of them were rejected. The client said things like, “Nah” and “Not exactly.” Eventually, after several paraphrases “misses” I managed to notice the pattern and share with the client, “I noticed that I’m trying to listen to you and understand what you’re saying, but I keep getting it wrong and you keep correcting me. I’m sorry for this and I appreciate you letting me know when I don’t quite get things right. If it’s okay with you, I’ll keep trying and you can keep correcting me when I get things wrong.” In situations like this one, it’s recommended that the counselor acknowledge the process reality in the session. Because, as Yalom has so articulately noted, commenting on process can be intense, it can be better to begin process commentary by noticing your own less-than-optimal patterns.

 9. Managing Countertransference

Research suggests that our countertransference reactions can teach us about ourselves, our underlying conflicts, and our clients (Betan, Heim, Conklin, & Westen, 2005; Mohr, Gelso, & Hill, 2005). For example, based on a survey of 181 psychiatrists and clinical Counselors, Betan et al., reported “patients not only elicit idiosyncratic responses from particular clinicians (based on the clinician’s history and the interaction of the patient’s and the clinician’s dynamics) but also elicit what we might call average expectable countertransference responses, which likely resemble responses by other significant people in the patient’s life” (p. 895). Countertransference is now widely considered a natural phenomenon and useful source of information that can contribute to counseling process and outcome (Luborsky, 2006). In fact, clinicians from various theoretical orientations have historically acknowledged the reality of countertransference.

Speaking from a behavioral perspective, Goldfried and Davison (1976), the authors of Clinical Behavior Therapy, offered the following advice: “The therapist should continually observe his own behavior and emotional reactions, and question what the client may have done to bring about such reactions” (p. 58). Similarly, Beitman (1983) suggested that even technique-oriented counselors may fall prey to countertransference. He believes that “any technique may be used in the service of avoidance of countertransference awareness” (p. 83). In other words, clinicians may repetitively apply a particular therapeutic technique to their clients (e.g., progressive muscle relaxation, mental imagery, or thought stopping) without realizing they are applying the techniques to address their own needs, rather than the needs of their clients. There are many moments to reflect on how countertransference dynamics might affect the counseling process during the workshop. More recent research affirms that identifying and working through countertransference is associated with positive counseling and psychotherapy outcomes (see: Norcross, 2011).

To deal effectively with countertransference requires the following possibilities:

  • The counselor is aware of the possibility
  • The counselor seeks supervision
  • The counselor gets counseling
  • The counselor owns his/her/their countertransference reaction in the session and makes a commitment to dealing with it effectively

 10. Progress Monitoring

Progress monitoring occurs when counselors routinely and formally check in with clients regarding the clients’ progress. This “checking in” can focus on the counseling relationship/alliance or on symptom improvement. At a very basic level, counselors can check in informally, like Carl Rogers often did (e.g., “Am I getting that right?”

 More formal progress monitoring can involve use of formal scales like the session rating Scale and the Outcomes Rating Scale. You can find these instruments online.

The most important part of progress monitoring may be as simple as you, the counselor, showing interest in the client.

 A Bonus Technique

 As a method for deepening your understanding of the EBRFs, I recommend that you watch some counseling sessions with the intent to “see” the EBRFs in action. To give you an opportunity for that, I’m offering this bonus technique and an accompanying video clip.

 The Three-Step Emotional Change Trick: Emotions are complex. Young people need strategies for dealing with negative affect. The three-step emotional change trick is one method for providing emotional education. For details, and a video demonstration, see: https://johnsommersflanagan.com/2017/03/12/revisiting-the-3-step-emotional-change-trick-including-a-video-example/

John S-F Resources

The main resources from which this handout is drawn are below, starting with my own publications and then continuing to additional citations.

Sommers-Flanagan, J. (2018). Conversations about suicide: Strategies for detecting and assessing suicide risk. Journal of Health Service Psychology, 44, 33-45.

Sommers-Flanagan, J., & Shaw, S. L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48, 98-106.

Sommers-Flanagan, J. (2015). Evidence-based relationship practice: Enhancing counselor competence. Journal of Mental Health Counseling, 37, 95-108.

Sommers-Flanagan, J. (2018). Suicide assessment and intervention with suicidal clients [Video]. 7.5 hour training video for mental health professionals.  Mill Valley, CA: Psychotherapy.net.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (3rd ed.). Hoboken, NJ: Wiley.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical Interviewing (6th ed.). Hoboken, NJ: Wiley.

Sommers-Flanagan, J. (2016). Assessment strategies. In M. Englar-Carlson (Ed.). The skills of counseling [Video]. Alexandria, VA: Alexander Street Press.

Sommers-Flanagan, J. (2015). Evidence-based relationship practice: Enhancing counselor competence. Journal of Mental Health Counseling, 37, 95-108.

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., & 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. (2018). Clinical interviewing (6th ed.). Hoboken, NJ: John Wiley & Sons.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (3rd 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.

Selected References

Betan, E., Heim, A.K., Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162 (5), 890 – 898.

Castro-Blanco, D., & Karver, M. S. (2010). Elusive alliance: Treatment engagement strategies with high-risk adolescents. Washington, DC: American Psychological Association.

de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.

Feindler, E. (1986). Adolescent anger control. New York: Pergamon Press.

Kolden, G. G., Klein, M. H., Wang, C., & Austin, S. B. (2011). Congruence/genuineness. Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.) (pp. 187–202). New York, NY: Oxford University Press.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Preparing people for change (3rd ed.). New York: Guilford Press.

Norcross, J. C. (Ed.). (2011). Evidence-based therapy relationships. Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). New York, NY: Oxford University Press.

Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315.

Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.

Shirk, S. R., Karver, M. S., & Brown, R. (2011). The alliance in child and adolescent psychotherapy. Psychotherapy, 48, 17-24.

Villalba, J. A., Jr. (2007). Culture-specific assets to consider when counseling Latina/o children and adolescents. Journal of Multicultural Counseling and Development, 35(1), 15-25.

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.

If you have questions about this handout, or are interested in having John SF conduct a workshop or keynote for your organization, contact John at: john.sf@mso.umt.edu. You may reproduce this handout 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