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Clinical Interviewing

Nice Review

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Victor Yalom of Psychotherapy.net recently emailed us a copy of a review of our Clinical Interviewing DVD. This is a wonderful review from someone we’ve never met . . . but we think we’d like him. He’s a professor at Western Illinois University.
Here’s an abstract of the review.
Interviewing with humanity intact.
By Knight, Tracy A.
PsycCRITIQUES, Vol 60(9), 2015, No Pagination Specified.
Abstract
Reviews the video, Clinical Interviewing: Intake, Assessment & Therapeutic Alliance by John Sommers-Flanagan and Rita Sommers-Flanagan (2014). This video blends the procedural with the human in a way that will enhance and deepen the training of mental health professionals. Beyond describing the most valuable guidelines of clinical interviewing, John and Rita Sommers-Flanagan provide multiple illustrative interviews with clearly nonscripted participants. Most importantly, the Sommers-Flanagans discuss both the information as well as the interviews, displaying both their depth of knowledge and perhaps the most important attributes of gifted clinicians: humility and curiosity. They not only provide a map, therefore, but also fully display and describe the landscape that interviewers and their clients traverse. The DVD includes seven distinct areas of focus, each one building on the previous. Initially, the authors succinctly describe basic listening skills, including both nondirective and directive approaches. Their definitions are clear and evocative, and during the sample interviews, the distinct attributes of the therapist’s actions are listed for viewers. This sets the stage for the authors’ subsequent discussion, during which they explore the dynamics of the sample interview and lucidly discuss important human factors. The reviewer concludes this video offers both knowledge and wisdom, providing students and trainees with an approach to clinical interviewing that makes the process more efficient, while always respecting the beating heart of humanity that rests within it. (PsycINFO Database Record (c) 2015 APA, all rights reserved)
Cool Counseling, Counseling and Psychotherapy Theory and Practice

Secrets of the Miracle Question

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This is a re-post from the American Counseling Association Blog.

You might want to sit down because this could take a while.

Developed in the 1970s by Insoo Kim Berg and Steven de Shazer, the miracle question has become a very popular therapy intervention. It’s standard fare for solution-focused therapists and has been written about extensively. In 2004, Linda Metcalf wrote a whole book about it and in 2010 Ryan Howes of Psychology Today declared it the #10 most “cool” intervention in psychotherapy.

To be honest, I have mixed feelings about the miracle question. Although I’ve used it with clients and found it helpful, I’ve never found it the least bit miraculous. It’s a good and clever question that helps clients focus on goals. But it’s no miracle.

My biggest problem with this intervention is the use of the word miracle. Miracles are, by definition, highly improbable, highly desirable, not explained by natural causes, and typically ascribed to divine intervention. Wow. That IS cool…

Using the word miracle to describe a common goal-setting question is excellent marketing. The only thing better might have been to call it the secret miracle question. But as I write this I hear the voice of Rich Watts in the back of my head muttering something about how everybody steals the work of Alfred Adler without giving him credit. Rich is President of the North American Society for Adlerian Psychology. My inner Rich Watts voice is noticing that the miracle question looks a lot like “The Question,” an intervention used and written about by Alfred Adler in the early 1900s. Adler’s version went: “How would your life be different if you no longer had this problem?” Again, good question, but no miracle. And hardly anyone (other than Rich Watts and his Adlerian buddies) ever mention The Question anymore.

If I dig a little deeper, what I find most problematic is that the word miracle leads counseling students and practitioners to adopt one or more of three false beliefs. They begin believing that the miracle question is: (a) a simple procedure, (b) easy to learn and implement, and (c) that it can result in a miracle. Sadly, none of these beliefs are true.

An example from popular literature might help. Think about how long it took Harry Potter to learn the Tarantallegra spell. In case you can’t recall, the Tarantallegra spell forces one’s opponent to dance. I don’t know long it took the fictional Harry Potter to learn the fictional Tarantallegra spell, but I’m certain that even in the fictional world created by J. K. Rowling it wasn’t during his first year at Hogwarts.

The miracle question name erroneously implies something quick and easy and miraculous is happening. Sort of like snapping your fingers and reciting that Tarantallegra incantation. You can try it that way, but it won’t work…because you won’t be manifesting an understanding of the incantation. I’ve seen novice counselors try the miracle question and the most common client response elicited is: “I don’t know.” This is because counseling miracles require sophisticated language and delivery skills, a solution-focused mindset, and education and experience.

The miracle question is all about sophisticated verbal behavior. We should recall that Berg and de Shazer were strongly influenced by the renowned hypnotherapist, Milton Erickson. This is one reason why, when done well, the miracle question resembles a hypnotic induction. Even de Shazer and his colleagues noted that it might take an entire therapy session to ask and explore the miracle question (see the book, More Than Miracles).

Although many published variants of the miracle question exist, below I’m including a detailed version, as described by Insoo Kim Berg and Yvonne Dolan in Tales of Solutions. As you read through this example, remember: The miracle question should be spoken slowly, there should be repeated pauses, and the therapist should deeply believe in the solution-focused principle that all clients already possess the inherent competence to produce positive changes in their lives. Here’s the question:

I am going to ask you a rather strange question [pause]. The strange question is this: [pause] After we talk, you will go back to your work (home, school) and you will do whatever you need to do the rest of today, such as taking care of the children, cooking dinner, watching TV, giving the children a bath, and so on. It will become time to go to bed. Everybody in your household is quiet and you are sleeping in peace. In the middle of the night, a miracle happens and the problem that prompted you to talk to me today is solved! But because this happens while you are sleeping, you have no way of knowing that there was an overnight miracle that solved the problem [pause]. So, when you wake up tomorrow morning, what might be the small change that will make you say to yourself, “Wow, something must have happened—the problem is gone!” (Berg & Dolan, 2001, p. 7, brackets in original)

If you’re by yourself, you might want to go back and read through the miracle question again. This time read it aloud. Think of a small problem of your own and freely insert a few references to it.

Technically, the miracle question is a projective or generative assessment tool and hypnotic induction strategy. This is because it asks clients to project themselves into the future and generate information or scenarios straight from their imaginations. Together, counselor and client create a virtual reality and then try to make it a real reality. This is where I agree with fans of the miracle question: That’s one cool intervention. It makes me want to dance.

Therapy with Adolescents, Tough Kids Cool Counseling

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

Personal Reflections, Writing

My Adams State University Chi Sigma Iota Initiation Speech

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It’s an honor to be here on this excellent almost-spring-day in Alamosa, Colorado. Thanks to Jazmin, Chris, and Lori for inviting me here and arranging this visit. I’m so touched about this that I wrote a song especially for this event. And so you’ve got that to look forward to.

When it comes to giving speeches and workshops, one of my former professors used to say this: If you ask me to give a 15 minute talk, I’ll need all day to prepare; if you ask me to talk for a couple hours, I’ll likely need a couple hours of prep. But if you want me to talk all day . . . I’m ready.

This is why I have some verbatim notes here. Tomorrow I’ll be talking all day and therefore be way more spontaneous. Today, I need a guide to keep me focused.

The first thing I’d like to report is that the profession and discipline of Counselor Education is doing well . . . and maybe even booming. Just last night at the University of Montana we held our live group admissions interview for our CACREP-accredited Clinical Mental Health and School Counseling M.A. Programs. We have a total of 18-20 openings for these degrees and 71 applicants. About 45 applicants showed up for a 2 ½ hour group interview. After the interview, late into the night, we were discussing the applicants and one of our current students who was helping with the process exclaimed, “Thanks for letting me be a part of this. This was like Fantasy Football in February.” We took that as a compliment.

This is why I LOVE being a Counselor Educator. I don’t love it for the Listserv, or the ACA convention, or the status and prestige of being a Counselor Educator and teaching at the University of Montana. I love it because every year I get to spend most of my time teaching the kindest and most respectful graduate students on the planet; students who are deeply committed to helping others and to making the world just a little bit better place for individuals, couples, families, groups, schools, and communities. I have the honor of teaching these great people and maybe partly because we teach them how to have awesome listening skills, when I teach, they actually look like they’re listening to me. This is the best job ever.

And so thanks for letting ME be a part of THIS Excellent Day and CSI Induction Ceremony. It’s definitely better than fantasy football in February.

What I hope is that this is not just an initiation ceremony . . . it should also be a celebration . . . which brings up an important question: “How shall we celebrate?”

Well, of course, there should be dancing . . . and singing . . . and maybe some slam poetry . . . and of course, high fives all around, and arms raised in the air, and clapping and cheering (woo hoo) and toasting and smiling and laughing and eating desserts. Let’s do it all!

Counseling is a profession and identity that comes from the people. From way back in 1909, with Frank Parsons publishing “Choosing a Vocation” (with Pauline Agassiz Shaw’s unwavering financial and emotional support), it had become clear that modern citizens from the early 20th Century could benefit from assistance in making important decisions.

Think about that. Where do we learn to make decisions? Not just decisions about vocation and career, but other important life decisions? Did your parents explicitly teach you? Did you take a “Decision-Making” course in high school or college? Did you enroll in a life decision-making workshop? Probably not. Sometimes I think it’s mostly only in graduate school where Counselor Education students get taught how to make decisions and how to help people make important decisions.

This is still a big part of what we, as counselors, do. We help people make everyday life decisions. We help them sort through the thoughts, feelings, impulses, and social and cultural forces that make decision-making so challenging. And we help them make bigger decisions too.

Counseling is a profession with roots back in the early 1900s with Frank and Pauline, but professional counseling is a much more recent development.

Not long before Thomas Sweeney of Ohio University founded CSI in 1983, it was becoming apparent that Psychiatry, Psychology, and Social Work weren’t adequately serving the needs of all the people. In the 1960s and 70s, Psychiatry was mostly taking the BIG PHARMA road, Social Work mostly linked hands with Medical professionals, and Psychology mostly decided to embrace Ph.D.-only training, a sort of scientific fundamentalism, and the pursuit of becoming mini-physicians.

IMHO, this was a mass exodus from the needs of most people. Helping became much more about the medical model – assessment, diagnosis, and treatment – and less about helping people achieve what most of us really want in our daily lives, good health and positive wellness.

So there was something big missing. People wanted to work with professional practitioners who were empathic, kind, compassionate, and positive, and interested in helping them feel WELL, instead of just helping them not feel sick. This is the breech into which professional counseling stepped. And this is probably why, in a study conducted in the Psychology Department at the University of Montana in 1991, it was reported that consumers rated Counselors as warmer, kinder, more genuine, and more desirable to see than Psychiatrists or Psychologists.

At the University of Montana we have an MSW, a Clinical Psychology, and our Counselor Education graduate programs. Not surprisingly, we have a bit of a friendly competition for graduate students. Don’t get me wrong, I love my colleagues in Psychology and Social Work and I think they do a fantastic job educating their students; I just think their professional disciplines have gotten drawn a bit too far over into the medical model. Consequently, when prospective students ask me what program they should choose, I find it very easy to say, “If you want to learn how to do, I mean, really how to do individual, couple, family, and group counseling, then you should join us in the Department of Counselor Education.” Even the graduate students in these respective programs recognize that Counselor Education students learn these skills faster than other disciplines . . . principally because that’s what we focus on.

This brings me to some concerns for the future.

There will always be medical creep, pharmaceutical creep, and insurance company creep. The medical model is strong and compelling. We have to watch out for that. For example, right now we’re right in the middle of a Neuroscience party that’s dominating popular discourse. This reminds me of a Psychiatrist with whom I worked at a Psychiatric Hospital back in 1981. He said it wouldn’t be long until we were all taking drugs to manage and moderate our emotions and behaviors. Well, mostly he was wrong.

Now we have “brain-based” this and “brain science” that and to be “in the dominant cultural discourse club” we have to put “neuro” in front of every other word or sentence.

But there are some surprising ways in which the medical model and neuroscience don’t provide much guidance or truth.

There’s really no such thing as a chemical imbalance. If you speak Spanish and I don’t, then our unique brains have to be different. The chemical imbalance as an explanation for mental health problems has no particular scientific support.

In addition, the track record of psychiatric medications curing illness is rather abysmal. I’m not saying that medications never work, I’m just saying they work less well than most of the public has been led to believe.

And the majority of the quantitative research published in psychology journals is, to borrow Carl Rogers’s words from 1957, “for the most part, a colossal waste of time.”

My point here is: Let’s be damn good professional counselors, and not try to be like those other professional disciplines. They have their niche; they’re needed in some ways for some things. But let’s stick with what we’re doing well.

As I’m sure you all know, because I don’t have a portable MRI or PET scanner in my office—which wouldn’t allow me to really “see” what’s happening in someone’s brain anyway—there’s really only one good method for me to know what’s going on in my client or student’s brain.

The best way to do this is to sit with the person and listen well and develop a trusting relationship and ask things like:

• What are you thinking right now?
• What do you want?
• What emotions are coming up for you?
• What feelings and sensations do you have in your body?

Being with people in positive therapeutic relationship and sometimes asking no questions at all, is the best brain scanner we’ve got.

And here are a few more important truths:

1. A pill is not a skill
2. There’s no better medicine than a healthy and caring relationship, and
3. The profession that is currently doing the best at focusing on skills and relationships is Counselor Education!

As the EMDR therapists would say, “Let’s go with that.”

Before ending, I’d like to tell one short story; then we can officially start celebrating.

Meeting Jesus at the Portland VA Story: What this psychotic patient wanted and what he responded to was what most of us want and respond to . . . to be listened to . . . and to be treated with respect and as an individual, not as a psychiatric label.

Now let’s begin our official celebration with a song that I wrote especially for this auspicious occasion. Ready? I’ll sing it through first and then you can all stand if you like and join me:

Oh, I wish I were a counselor-in-training, counselor-in-training . . .
Oh, I wish I were a counselor-in-training, counselor-in-training . . .
I think it’d be rather swell
To help everyone be well
Oh, I wish I were a counselor-in-training, counselor-in-training.”

Everybody now . . .

Thanks for listening and my BIG congratulations to all of the initiates and the faculty here at Adams State University.

Uncategorized

One More Montana Love Workshop Promo: You’ll Get to Learn from the Amazing Dr. Jon Carlson

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Hello Mental Health Professionals.

I’m writing to remind you to register for our Spring LOVE Workshop series through the Department of Counselor Education. Although the WHOLE conference includes content that can be useful in your professional and personal lives, in particular, I want to point out that, for the Friday, March 20 date we have the honor of hosting and learning from Dr. Jon Carlson and it’s not often we get someone with the immense experience and expertise of Jon Carlson.

If you don’t already know who Jon Carlson is, here’s an official bio on him:

Jon Carlson, PsyD, EdD, ABPP is Distinguished Professor, Psychology and Counseling at Governors State University and a psychologist at the Wellness Clinic in Lake Geneva, Wisconsin. Jon has served as editor of several periodicals including the Journal of Individual Psychology and The Family Journal. He holds Diplomates in both Family Psychology and Adlerian Psychology. He has authored 175 journal articles and 60 books including Time for a Better Marriage, Adlerian Therapy, Inclusive Cultural Empathy, The Mummy at the Dining Room Table, Bad Therapy, The Client Who Changed Me, Their Finest Hour, Creative Breakthroughs in Therapy, Moved by the Spirit, Duped: Lies and Deception in Psychotherapy, Never Be Lonely Again, Helping Beyond the Fifty Minute Hour, How a Master Therapist Works and Being a Master Therapist. He has created over 300 professional trade video and DVD’s with leading professional therapists and educators. In 2004 the American Counseling Association named him a “Living Legend.” In 2009 the Division of Psychotherapy of the American Psychological Association (APA) named him “Distinguished Psychologist” for his life contribution to psychotherapy and in 2011 he received the APA Distinguished Career Contribution to Education and Training Award. He has received similar awards from four other professional organizations. He has also syndicated the advice cartoon On The Edge with cartoonist Joe Martin. Jon and Laura have been married for forty-seven years and are the parents of five children.

Obviously, Jon Carlson is highly acclaimed within both the Counseling and Psychology disciplines and I don’t think you should pass up a chance to see him live in Montana.

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

There are now two ways to register for the WHOLE conference or for a single session.

1. You can print and fill out the registration form that follows and mail it in the old fashioned way, or
2. You can go online and register and pay through the Children’s Museum website. Go to: https://www.childrensmuseummissoula.org/ and scroll down about half a page.

If you decide to pay online and you don’t want to fill out and mail the registration form, drop me an email at: John.sf@mso.umt.edu and let me know you’re signed up and I’ll make sure we have a form ready for you to fill out at the workshop so you can avoid having to hassle with mailing it.

Finally, for those of you have read this far and want to know more about Jon Carlson’s presentation in Missoula, here’s a description in his own words:

Adlerian Brief Couples Therapy

There has been considerable debate and negative press in recent times over brief therapy and whether or not it is in the best interests of clients. Most therapists/counselors fail to realize that most clients want brief treatment. They want to get help as soon as possible. People do not have unlimited time or money to spend on therapy no matter how valuable counselors and therapists think their services are. Most want help and are not looking for a paid-for friend.

Another truth is that most therapy is brief as clients attend treatment for usually less than 6 sessions with one being the modal number. Managed care companies are quick to remind us that most gains in therapy occur early and tend to diminish as treatment continues. It would unprofessional to act as if some clients cannot benefit from long term treatment. There are conditions in which longer treatment is necessary but this is the exception and not the rule.

Most clients really do not want to be seeing therapists. They wish there lives worked and that they were “normal.” It is important for effective therapy to understand that this is the case and to provide as efficient a treatment as possible.

This program will focus on how to do brief therapy with couples. I will talk about brief therapy from an Adlerian theoretical orientation as well as the skills of a healthy relationship. The participants will also be able to see the process applies as I work with an actual couple and help them resolve some of their current challenges.

That sounds pretty cool to me and so I’m planning to be there.

That’s it for now. Have a great rest of the week and I hope to see you at one or more of the workshops.

Sincerely,

John SF

John Sommers-Flanagan, Ph.D., Professor
Department of Counselor Education
Phyllis J. Washington College of Education and Human Sciences
University of Montana
32 Campus Drive
Missoula, MT 59812
406-243-4263 (office); 406-721-6367 (cell)
John.sf@mso.umt.edu
Johnsommersflanagan.com

And here’s a photo of Dr. Carlson

JC 2010c

 

Parenting

How to Talk so Parents will Listen: Strategies for Influencing Parents

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Last June I had a chance to go to Chicago to be filmed doing three professional THERAPY TALKS. It was a challenging situation; just me and a camera and a few production folks. One of the TALK topics focused on how to work effectively with parents. As it turns out, this video and others I’ve done with Microtraining are now available at their website: https://www.academicvideostore.com/publishers/microtraining (you have to search for Sommers-Flanagan).

Here’s the text, more or less, from the “How to Talk so Parents will Listen” TALK.

When I talk with large groups about parenting, I like to begin with a survey. I ask: “How many of you ARE parents?” Of course, nearly everyone raises his or her hand. Then I ask a follow up: “How many of you WERE children.” At this question some participants laugh and a few raise their hands and others joke that they’re still immature.

This reason I start with this survey is because if you’re a parent, you know that being a parent is an amazing and gratifying challenge. You also know that it’s 24-7; and you know it doesn’t end when your child turns 18. You’re a parent for life. And if you WERE a child, and all of you were, then you know how important it is to have a parent or caretaker who makes it perfectly clear that YOU ARE LOVED. But there’s more. If you were a child, then you also know how important it is to have a parent who not only loves you, but who is skillful . . . a parent who is dedicated to being the best parent possible.

Plain and simple: PARENTS NEED SKILLS FOR DEALING WITH THEIR CHILDREN IN THE 21ST CENTURY. And learning to be a better parent never stops.

Once upon a time I had a mom come consult with me about her five year old son. She said: “I have a strong-willed son.” My response was to acknowledge that lots of parents have strong-willed children. She said, “No, no, you don’t get it. I have a very strong-willed son, let me tell you about it. Just the other night, I asked him to go upstairs and clean his room and he put his hands on his hips and said, “NO.” So I said in response, “Yeah, yeah. He sounds very strong willed.” And she said, “Wait. There’s more. I asked him to clean his room a second time and he glared and me, and said “NO. YOU WANT A PIECE OF ME?” Then she told me the real problem. The problem was that, in fact, she did want a piece of him at that particular point in time and so she grabbed him and hauled him up the stairs in a way that was inconsistent with the kind of parent she wanted to be.

This is one of the mysteries of parenting. How can you get so angry at a small child whom you love more than anything else in the world?

Parents are a unique population and deserve an approach to counseling that’s designed to address their particular needs. In this talk I’ll mostly be using stories to talk about:

a. what parents want for their children
b. what parents need in counseling
c. and how professionals can be effective helpers.

Most parents want some version of the same thing: To raise healthy and happy children who are relatively well-adjusted. But what do parents need in counseling. WHAT WILL HELP THEM GET WHAT THEY WANT?

First, parents need empathic listening. They need this big time. Our American culture puts lots of social pressure on parents . . . It’s implied that parenting should be easy and all parents should want to spend 24-7 with their child in an altered state of parental bliss. But this isn’t reality and so we need empathy for the general scrutiny parents feel in the grocery store, at church, on the playground, and everywhere else.

But they also need listening and specific empathy: like in the situation where the mom wanted to tell me about her 5-year-old son. She had specific information to share and it was really important for me to take time to listen to her unique story about her son who, unfortunately, may have seen too many Clint Eastwood movies.

Parents come to counseling or parent education feeling simultaneously insecure and indignant. They feel insecure because of the scrutiny they feel from their parents and in-laws and society, but they also feel indignant over the possibility that anyone might have the audacity to tell them how to parent their children. As professionals, we need to be ready to handle both sides of this complex equation.
Another thing parents have taught me over the years is to never start a parenting session by sharing educational information. You should always wait to offer educational advice, even when parents ask you directly for it. When they do ask, let them know that your ideas will be more helpful later once you get to know what’s happening in their family.

This leads us to the second crucial part of what parents need in counseling. They need collaboration. We can’t be experts who tell parents what to do, instead we have to recognize that parents are the experts in the room. They’re the experts on their children, on their family dynamics, and on themselves. If we don’t engage and collaborate with parents, very little of what we offer has any chance of being helpful.

Parents also need validation to counter their possible insecurity. We call this radical acceptance or validation and it involves explicitly and specifically giving parents positive feedback. We do this by affirming, “You sure seem to know your daughter well.” And by saying, “When I listen to how committed you are to helping your son be successful in life, I can’t help but think that he’s lucky to have you as a parent.”

And so we begin with empathic listening and we move to collaboration and we make sure that we offer radical acceptance or validation and we do all this so we can get to the main point: providing parents with specific parenting tips or guidance.
And there are literally TONS of specific parenting tips that professionals can offer parents. Most of the good ones include four basic principles:

First, getting a new attitude – because developing parenting skills requires a courageous attitude to try things out.

The second one involves making a new and improved plan. Because a courageous attitude combined with a poor plan won’t get you much.

Third is to get support when you need it. Parenting in isolation is almost always a bad idea.

Fourth, underlying all tips there should be the foundation of being consistently loving.

I’d like to tell two parenting stories to illustrate all of the preceding ideas.

This first story is about a parenting struggle I had. I share it for two reasons: One is that it’s a great example of the need for parents to make a new plan to handle an old problem. And two, often it’s good to self-disclose—but not too much—when working with parents.
When my youngest child was 5-years-old, she ALSO was a strong-willed child. I vividly recall one particular ugly scene on the porch. It was time for us to leave the house. But we lived in Montana and there was snow and my daughter needed to put her boots on. Funny thing, she was on a different schedule than I was. This created tension and anger in me. And so I got down into her face and I yelled GET YOUR BOOTS ON! And her eyes got big and she did. Later that evening I was talking with my wife and she saw the scene and she said to me, “I know John, that’s not the kind of parent you want to be.” And even though it’s not easy to take feedback from our romantic partners, she was right and so obviously so, that I had no argument” which led me to tell her, “I’m not going to yell at our daughter any more. I am, instead going to whisper, because I learned in a parenting book, that sometimes when you’re angry it’s more effective to whisper than it is to yell. That was my new plan. Of course, like new plans everywhere, it needed tweaking. But it didn’t take long for me to have an opportunity to test it because if there’s anything on the planet that’s predictable, it’s that we’ll all soon have another chance to manage our anger toward our children more constructively.

It was the next day or week and my daughter did not get her boots on and she was not on the same schedule as me and I got down in her face, once again, but I remembered the plan to whisper and I did my best to transform my anger from the historical yell to the contemporary whisper and what happened was that what came out was sort of like the exorcist and I said to my daughter: “GET YOUR BOOTS ON!”

Now. I wasn’t especially proud of that, but she got her boots on.

It was the beginning of a big change for me because I learned I could play the exorcist instead of yelling; then I learned to growl and then I learned to count to three and then I learned a cool technique called Grandma’s rule where you use the formula, WHEN YOU, THEN YOU to set a limit and build in a positive outcome. Like . . . “Honey, when you get your boots on, then you can have your cell phone back.” Very cool.

What I learned from this experience is that I could be more than a one-trick parenting pony. I became the kind of parent who, although far from perfect, was able to set limits that were in my daughter’s best interest.

And what I like the best about this particular story is that daughter is now 26 years-old and she still says the same thing she used to say to me when she was 15 . . . that is, “Dad, one thing I really love about you is you never yell.” What’s cool is that I did yell, but I worked on it, I made a new plan, and now she doesn’t even remember the yelling.

I’d like to finish with one last story about how much parents need people like you to have empathy, collaborate, validate, and offer concrete parenting ideas.

I was working with a 15-year-old boy. His mom was bringing him to counseling because he and his dad weren’t speaking anymore. I hadn’t met the dad, but one day, when I went to the boy’s IEP meeting at school the dad was there. I saw this as a chance to make a connection and get him to come to counseling.

I did a little chit-chatting and sat next to him in the group meeting. Then, at one point, I asked the boy a question: “If you got an A on a test, who would you show first?” He answered, “I’d show my dad, my mom, and my special ed teacher.” This inspired me to turn to his dad and say, “It’s obvious that you’re very important to your son and so I’d like to invite you to come join him and me in counseling.” Dad gave me a glare and pushed my shoulder and began a 2-minute rant about how the school had failed his son. Everyone was stunned and then he turned back to me and said, “I’ll come to counseling. I been to counseling before and I can do it again.”

At that point I wondered if I could take back my offer.

The day the dad drove to counseling he and his son weren’t speaking, so I met with them separately. The son was clear that he would never speak to the dad again, but the dad was open. When I asked if I could offer him some ideas, he said, “Well I tried MY best and that dog don’t hunt, so I can try something else.” I was wishing for subtitles.

I told the dad I wanted him to keep his high standards for his son, but to add three things. First, I asked, do you love your son? The dad said “Yes” and so I told him, “Okay then. I want you to tell him ‘I love you’ every day.” He said, “Usually I leave that to the wife, but I can do that.” Second, I said, “Everyday, I want you to touch your son in a kind and loving way.” He asked, “You mean like give him a hug?” I said, “that would be great” and he responded, “Usually I leave that to the wife too, but I’ll give it a shot.” Third, I said, “Once a week, you should do something fun with your son, but it has to be something that he thinks is fun.” He said back: “That’s no problem. We both like to go four-wheeling, so we’ll do that.”

And they left my office for an hour-long of what I imagine was a silent trip home.

The next afternoon, I got a call from the mom. She was ecstatic. She said, “I don’t know what you did or what you said, but they’re talking again.” And then she added, “This morning, when they were in the kitchen, I was in the other room and I thought I heard them hug and when I saw my son walking down the driveway to head to school, there were tears running down his cheeks.”
This was obviously a mom who was listening and watching very closely.

Things got much better for the 15-year-old after that. He didn’t get straight As, but he stopped getting straight Fs. And I learned two things: First, I learned just how much that boy needed to get reconnected with his father. And second, I learned that sometimes, no matter how gruff parents may seem, what they need is some clear and straightforward advice about how to reconnect with their son or daughter.

My final thoughts about this topic are very simple. I hope you’re inspired enough to acquire the knowledge and skills it takes to work effectively with parents. I know their children will deeply appreciate it.

Thanks for listening.

John and Nora

Couple Counseling, Love

Upcoming Workshops on Love and Couple Counseling at the University of Montana

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Starting on February 27, 2015, the Department of Counselor Education at the University of Montana will be offering a “LOVE” Workshop Series on campus in Missoula. This workshop series will include four different full-day trainings. The dates, topics and presenters for this series is below . . . and a registration form is attached. Registration form LOVE – Final

Session I: Friday, February 27, 2015, 8:30-4:30
Part One: Facilitating Intimate Conversations
Presented by: Veronica Johnson, Ed.D. and Kirsten Murray, Ph.D. – University of Montana

In American culture, romantic partners are taught to dread having serious relationship talks. This workshop focuses on helping couples build positive expectations and effective skills for communicating directly about their relationship and relationship issues like sex, money, and in-laws.

Part Two: The Business of Working with Couples
Presented by: Jana Staton, Ph.D. – Independent Practice – Marriage Works

Although helping couples have happier and healthier relationships is intrinsically rewarding, if you’re a professional counselor or therapist, you probably want to get paid too. In this workshop, Jana Staton, Ph.D. will offer tips for maximizing the efficiency of the business side of your couples counseling practice.

Session II: Friday, March 20, 2015, 8:30-4:30
Romantic Relationships as Healthy Partnerships:
Adlerian Approaches to Couple Counseling and Education
Presented by: Jon Carlson, Psy.D., Ed.D. – Governor’s State University

In this workshop, Jon Carlson, Psy.D., Ed.D., author of 60 books and producer of over 300 counseling and psychotherapy training videos, will provide training on the Adlerian approach to couple counseling. His presentation will include two main parts: (a) a discussion of the relationship enhancement activities of TIME (Training in Marriage Enrichment), and (b) a focus on the principles and practices of Adlerian couple counseling (including a live case demonstration!).

Session III: Friday, April 24, 2015, 8:30-4:30
Emotion-Focused Couple Counseling
Presented by: Mark Young, Ph.D., Gonzaga University

Based on a foundation of attachment theory, emotion-focused couples therapy is currently one of the most popular and scientifically-supported approaches to working effectively with romantic couples. In this workshop, Mark Young, Ph.D., will help you understand the theoretical foundations and learn practical skills necessary to using emotion-focused couples therapy in your practice.

Session IV: Friday, May 8, 2015, 8:30-4:30
Part One: Complications of Love: The Challenge of Parenting
Presented by: Sara Polanchek, Ed.D. and John Sommers-Flanagan, Ph.D.

Researchers consistently report that romantic relationship satisfaction decreases with the birth of the first child and continues to decrease for about the next 20 years. The focus of this workshop will be on how parents can parent as partners and sustain their love and romance through the childrearing years.

Part Two: Complications of Love: Aging Well Together
Presented by: Catherine Jenni, Ph.D. and Jana Staton, Ph.D.

Recent research has surprising scientific findings from neuroscience, health outcome studies, and clinical trials about the effects of interactions with those we love on our immune, cardiovascular, and nervous systems. This workshop will include tips and best practices on how to keep a couple relationship alive, even in the face of declining health, aging, or illness.

Boys and Men, Parenting, Personal Reflections

Wishing for a Super Bowl that Promotes Non-Violence

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It’s been a tough year for the National Football League. There was renewed emphasis (for a while) on the devastating brain damage caused by repeated concussions. Then there was the Ray Rice domestic violence incident. And then there was the Adrian Peterson child abuse incident. And now there’s the Aaron Hernandez trial for murder and weapons charges that started a couple days ago. All these scandals added up to big, bad publicity . . . so much so that the Fiscal Times noted in a recent headline that these incidents “Rocked the NFL.”

Then there was deflate-gate, the ridiculousness that led us to wonder if our football heroes might just be a bunch of cheats.

But wait.

Through all these scandals the NFL has continued laughing its way to the Bank with obscene gobs of money that could be used to wipe out Ebola or end child abuse. Last year, NFL commissioner Roger Goodell made about $44 million. Vegas odds are that he’ll do better this year. Super Bowl advertisings are doing just fine, thank-you. And Katy Perry may or may not have a wardrobe malfunction tomorrow evening, but you can bet there will be millions of viewers. The NFL is right on pace to increase its economic worth to something well over being a $9 billion dollar industry. Not bad. Talk about Teflon.

It’s clear the situation is hopeless and that the Juggernaut that is the NFL will stroll into the future without substantially addressing anything that might be remotely linked to a social virtue. Nevertheless, I can’t stop cheering for underdogs, and that leaves me with an array of dreams that are so silly that I’m embarrassed to admit them. That said, I’ll go ahead and embrace my embarrassment and tell you what I’m watching for tomorrow.

I’ll be watching to see how many advertising bucks are used to promote domestic violence or child abuse prevention. Will we see NFL players, coaches, owners, and the commissioner go on record to support sexual assault prevention? Might there be room for the tiniest of sprinklings of valuable educational public service announcements during the four hour Super Bowl feast?

I think not; but I hold out hope.

And here’s my biggest irrational wish. I’m wishing for the NFL to provide educational information about the dangers of corporal punishment. Adrian Peterson said something to the effect that all he did was send his kiddo out to get a stick so he could beat him with it, just like his Momma did to him. Peterson was talking about our great American tradition of believing that it’s a good thing for parents to hit their children.

Even more disturbing than the single Adrian Peterson incident is the fact that during a typical 4 hour time period (about the length of the Super Bowl broadcast) there are approximately 1,500 reports of child abuse . . . and so maybe, just maybe, we could use a little NFL-sponsored education here.

But what really smacks my pigskin is the fact that Adrian Peterson’s parenting philosophy is still alive and well on the internet. In particular, it’s featured on the website of Christian “parenting expert” James Dobson. Seriously. It’s on a Christian-based website. This is stunning not only because there’s a truckload of science telling us that hitting kids is linked to bad outcomes, but also because it’s pretty difficult to imagine the Jesus that I read about in the Bible hitting children with a stick . . . or advocating the hitting of children with a stick.

Now that it’s the 21st century and time for Super Bowl XLIX, shouldn’t we know better? Shouldn’t we know that we shouldn’t send our kids out to get sticks so we can beat them? Come on NFL . . . just share that fun fact. Just come out and say you don’t support beating children . . . and how about you take 0.001% of your net worth and use it to launch an educational campaign that will teach parents what to do instead of hitting kids.

That’s what I’ll be watching for tomorrow . . . if I can manage to stomach turning on the game at all.

Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

Resistance Busters: How to Work Effectively with Teens who Resist Counseling

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Young clients or students and their parents will sometimes be immediately resistant to your efforts to help them change. I don’t mean this in the old-fashioned psychoanalytic form of resistance that blames clients. I mean this as a natural resistance to change. I think we’ve all felt it. Someone has some helpful advice and we feel immediately disinclined to listen and even less inclined to follow the advice. I remember this happening with my father—even when he wanted to tell me something about sports. Of course, he knew a TON more about sports than I did, but logic was not the issue. When it comes to relationships and influencing people, logic is rarely relevant.

If we can buy into using the word resistance—despite the fact that Steve de Shazer buried it in his backyard and had a funeral for it, we would be likely to conclude that resistance behaviors are especially prominent among youth who view their presence in therapy as involuntary. Think of school, court, or parent referred children. Below, in an effort to capture what happens in these situations, Rita and I came up with what we call common resistance styles. Again, the point is not to blame clients or students; after all, they usually come into counseling or therapy with a history that makes their resistance totally natural. Besides, why should we expect them to pop into a therapist’s office and suddenly experience trust and share their deepest feelings.

In combination with these so-called resistance styles, we’ve also developed a range of possible therapeutic responses. To be with de Shazer’s (1985) solution-focused model and because they constitute a first best guess regarding how to respond to these particular resistance styles, we refer to these responses as “formula responses.” Keep in mind that if one formula response is ineffective, an alternative one may be used to reduce and manage this pesky resistance-like behavior.

Resistance Style: Externalizer/Blamer
This young person quickly blames everyone and everything for his or her problems. S/he may feel persecuted; there also may be evidence supporting his/her persecutory thoughts and feelings. Alternatively, the youth may simply have trouble accepting personal responsibility.

SAMPLE STATEMENT: “I would never have flunked science if it weren’t for my teacher. He sucks big-time.”

Formula Responses: One key to responding to this youth is to blatantly side with his or her affect. In the early stages, confrontation with this type of youth is generally ill-advised. For example, Bernstein (1996) states: “Despite a lack of evidence to back up their arguments, we listen carefully without passing judgment” (p. 45). The blamer is sometimes so hypersensitive to criticism that he sees it coming a mile away. Therefore, especially at the outset of therapy, therapists should be cautious about providing criticism or negative feedback. As the client blames others be sure to grunt and moan and say things like, “Oh yeah, I hate it when teachers aren’t fair.” or just use standard person-centered reflections, “You’re saying that being around your teacher really sucks . . .it feels real bad.”

Resistance Style: The Silent Youth
This youth may refuse to speak or may boldly claim that she doesn’t have to talk to you. This youth may have strong needs for power and control and/or may be afraid of what she might say during counseling.

SAMPLE STATEMENT: “I don’t have to talk to you. And you can’t make me.”

Formula Responses: For the completely silent youth who appears to be stonewalling, it may be useful to use a combination of youth-centered reflection of feeling/content and self-disclosure or forced teaming. For example, you might say: “Seems like you really don’t want to be here and you also really don’t want me to know anything about you.” And/or: “If I were you, I wouldn’t trust me either. After all, you were sent here by people you don’t trust and so you probably think I’m on their side. I’d like to prove I’m not on their side, but the only way we can really shock your parents (or probation officer) is by you talking with me and then you and I teaming up to help you have more control over your life.” In the case where the client boldly claims that she does not have to talk with you, it can be helpful to strongly agree with the youth’s assertion (and then simply inquire as to what has been happening in the youth’s life.: “You are absolutely right. You ARE totally in control over whether you talk with me and how much you talk with me.” Then, after a short pause say, “Now, what do you want to talk about?” Sometimes acknowledging the youth’s power and control can decrease his/her need for it.

Resistance Style: The Denier
This is the youth who Repeatedly says: “I’m fine” or “I don’t know” when neither statement is likely to be the truth. These youths can be especially frustrating to therapists because whatever life circumstances that led the youth to therapy are clearly difficult and progress might be made if the youth would admit to having problems. Unfortunately, these youths may have such fragile self-esteem that admitting that any problems are occurring in their lives is very threatening.

SAMPLE STATEMENT: “I’m fine, I don’t have any problems.”

Formula Responses: With youth who say, “I’m fine” we suggest one of two possible formula responses. First, you might say: “If you’re fine, then somebody in your life must not be fine, otherwise, you wouldn’t be here. So, tell me about who forced you to come and what his or her problems are?” The purpose of this statement is to get youths to at least become “blamers” so that you can side with the affect and start building rapport. Second, Bernstein (1996) suggests a statement similar to the following: “You may be right and you may be fine, but if you don’t talk with me about your life, I’ll never know whether you’re fine or not.” Suggested formula responses to “I don’t know” include: “Okay, then tell me something you do know about this problem” or “Tell me what you might say if you did know” or “Boy, it sounds like there are lots of things about your life that you don’t know anything about. We’d better get to work on figuring this stuff out” or John’s favorite, which is: “Take a guess.”

Resistance Style: The Nonverbal Provocateur
Some young clients are so good at irritating other people with their nonverbal behavior that they deserve an award. These youth are often keeping adults at a distance because they don’t trust that the adults will understand or appreciate their adolescent dilemmas. These youths also are notorious for being able to “piss off” their parents, teachers, probation officers, and therapists. They may do so through eye-rolls, sneers, lack of eye contact, or other irritating nonverbal behaviors. Analytic theorists believe this is because they have such profound self- hatred that they unconsciously believe they deserve to be treated poorly by others, especially adults (Willock, 1986, 1987).

SAMPLE STATEMENT: “Yeah, right. Duh” (while youth’s eyes roll back and she heaves a significant sigh).

Formula Responses: When faced with the nonverbal provocateur, we recommend using the strategy we have referred to elsewhere as “interpersonal interpretation” (See Tough Kids, Cool Counseling). This strategy includes several steps. First, the therapist allows the youth to make whatever disrespectful nonverbal behaviors she wants to, without acknowledgment. Second, after a substantial number of eye-rolls, etc., have occurred, the therapist makes a statement such as: “Are people treating you okay.” This statement is designed to provoke complaints from the youth about whomever has been treating her so poorly. Third, the therapist discloses his or her reactions to the nonverbal behaviors: “The reason I bring this up is because, for a moment, significant sigh).I felt like being mean to you.” Fourth, the therapist suggests that the youth may already realize why the therapist “felt like being mean” to the youth or discloses that these feeling arose in response to the youth’s nonverbal behaviors. Fifth, the therapist suggests that the reason other people are treating the youth poorly is related to eye-rolls, etc., outside of therapy. Sixth, the therapist inquires as to whether the youth has control over his/her irritating nonverbal behaviors. Seventh, the therapist encourages the youth to conduct an experiment to see how people treat him/her one day when using lots of eye-rolls and another day while not using eye-rolls.

Resistance Style: The Absent Youth
There are at least two types of absent youths. First, there are young people who arrive with their parent or parents, but who refuse to leave the waiting room. Second, there are young clients who, after an initial appointment, keep missing their subsequent appointments.
In either case, resistance is high. These youth may be even more afraid of therapy and losing power the control than other youth, who at least make it into the counseling office.

SAMPLE STATEMENT: “I’m not going back and you can’t make me.”

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Formula Responses: It’s essential that young clients or students not be “dragged” into the therapy office. Therefore, the youth is simply informed that the session(s) will proceed without the youth present but that the session will still be “about” the youth. Subsequently, the session focuses on parent education and family dynamics. During this session, therapist should offer and serve food and drink to the participating family members. Also, partway through the session (if the young client is in the waiting room) one family member may ask once more if the youth would like to join them in the meeting. However, this request should only occur once and it should not involve any pleading. For young clients who miss their appointments, an invitation letter as suggested by White and Epston may be useful or, if you’re more behaviorally inclined, a contingency program may be designed to provide the youth with appropriate reinforcers and consequences.

Resistance Style: The Attacker
Similar to Matt Damon in the film Good Will Hunting, some youth will try to provoke the therapist by attacking whatever therapist personal traits that he or she can identify. It may be office decor, personal items (e.g., family pictures), clothing, the office itself, the voice tone, body posture, attractiveness, etc. The attacker’s ploy is often clear from the outset: The best defense (aka: resistance) is a good offense.

SAMPLE STATEMENT: “I noticed that everyone else here has a bigger office than you. You have a shitty little office; you must be a shitty little therapist.”

Formula Responses: We believe that two rules are crucial with young clients who consistently verbally attack the therapist. First, unlike Robin William’s character in the popular movie, you should not attempt to “choke” the youth (even therapist’s though you may feel like choking the client). In other words, therapists should not respond defensively or offensively to attacks by the youth. Second, the therapist may interpret the youth’s behavior by clearly demonstrating that the comments, whether true or not, say much more about the youth than they say about the therapist. After a few interpretations of the youth’s underlying psychodynamics, the youth usually will cease and desist with the attacks because he or she sees that every attack comes back to him or her in the form of an interpretation.

Resistance Style: The Apathetic Youth
The apathetic youth is similar to the denier, except that the formidable strategy of simply not caring about anyone or anything is the primary defense. This defense often arises out of depressive or substance related emotional and behavioral problems

SAMPLE STATEMENT: “Trust me, I really don’t give a shit about anything you’re saying!”

Formula Responses: Hanna and Hunt (1999) recommended using a sub-personality or ego state approach to dealing with adolescent apathy. This approach involves three steps: (a) take great care to empathize with the youth’s apathy; this might involve saying things like, “Okay, okay, I get it, you really don’t give a shit.”; (b) after empathizing, use a question like, “I know you don’t care, but isn’t there a little part of you, maybe a voice in the back of your head or something, that worries, maybe only a tiny bit about what might happen to you?”; (c) focus on the part of the youth that acknowledges caring about what happens and eventually begin labeling the “caring” part of the adolescent as the “real” self, while reducing the apathetic part of the self to the “fake” self.

More information about how to work through resistance is in our Tough Kids, Cool Counseling book, which happens to have five 5-star ratings on Amazon. Check it out:

 

 

Clinical Interviewing, Suicide Assessment and Intervention

Suicide Risk Factors, Part III

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It’s been awhile since I started my holiday and post-holiday look at suicide risk factors. In previous posts I focused on Demographic and Ethnic Factors related to death by suicide and then on the broad category of Mental Disorders and Psychiatric Treatment. This post focuses on Personal and Social Factors that are linked to suicide.

Not to worry, soon I’ll be moving beyond this tragic but important topic.

The following is mostly an excerpt from our Clinical Interviewing text.

Social and Personal Factors

There are a number of social and personal factors linked to increased suicide risk. Many of these factors have been reviewed and integrated into Thomas Joiner’s interpersonal theory of suicide (Joiner & Silva, 2012; Van Orden et al., 2010).

Social Isolation/Loneliness
In a review of the literature, 34 research studies were identified that include support for social isolation as a suicide risk factor (Van Orden et al., 2010). These findings provide support for Joiner’s (Joiner & Silva, 2012) attachment-informed interpersonal theory of suicide. Van Orden et al (2008) described the two primary dimensions of Joiner’s interpersonal theory:

The theory proposes that the needs to belong and to contribute to the welfare of close others are so fundamental that the thwarting of these needs (i.e., thwarted belongingness and perceived burdensomeness) is a proximal cause of suicidal desire. (Van Orden et al., 2008, p. 72)

Interpersonal theory explains why a number of social factors, such as unemployment, social isolation, reduced productivity, and physical incapacitation are associated with increased suicide risk. Specifically, research indicates that divorced, widowed, and separated people are in a higher suicide-risk category and that single, never-married individuals have a suicide rate nearly double the rate of married individuals (Van Orden et al., 2010). Based on interpersonal theory, an underlying reason that these factors are linked to suicidality is because they involve thwarted belongingness and a self-perception of being a burden to family and friends, rather than contributing in a positive way to the lives of others.

In a fairly recent study, the suicide notes of 98 active duty U.S. Air Force (USAF) members were analyzed. Using Joiner’s interpersonal theory, results indicated strong themes of hopelessness, perceived burdensomeness, and thwarted belongingness. Overall, interpersonal risk factors were communicated more often than intrapsychic risk factors. (Cox et al., 2011).

Physical Illness

Many decades of research have established the link between physical illness and suicide. Specific illnesses that confer suicide risk include brain cancer, chronic pain, stroke, rheumatoid arthritis, hemodialysis, and HIV-AIDS (e.g., (Lin, Wu, & Lee, 2009; Martiny, de Oliveira e Silva, Neto, & Nardi, 2011). Overall, although physical illness is a major predictor, several social factors appear to mediate the relationship between illness and death by suicide. In particular, Joiner’s concept of becoming a social burden seems a likely contributor to suicidal behavior, regardless of specific diagnosis (Van Orden et al., 2010). Similar to previously hospitalized psychiatric patients, medical patients also exhibit higher suicidal behavior shortly after hospital discharge (McKenzie & Wurr, 2001).

Previous Attempts

Over 27 separate studies have indicated that suicide risk is higher for people who have previously attempted (Beghi & Rosenbaum, 2010). Van Orden et al. (2010) refer to previous attempts as “. . . one of the most reliable and potent predictors of future suicidal ideation, attempts, and death by suicide across the lifespan” (p. 577).

As one example, in a 15-year prospective British study of deliberate self-harm, repeated self-harm was a strong predictor of eventual suicide, especially in young women (Zahl & Hawton, 2004). By the study’s end, 4.7% of women who had repeatedly engaged in deliberate self-harm committed suicide as compared to 1.9% in the single episode group. In this study, deliberate self-harm was defined as intentionally poisoning or self-injuring that resulted in a hospital visit. The study concluded that repeated deliberate self-harm increases suicide risk in males and females, but is a particularly salient predictor in young females. This is the case despite the fact that some clients use cutting, burning, or other forms of self-harm to aid in emotional regulation. Overall the research suggests that self-harm that rises to the level of hospitalization is likely beyond that which enhances self-regulation and instead constitutes practicing or successive approximation toward suicide.

Unemployment

Individuals who have suffered any form of recent, significant personal loss should be considered higher suicide risk (Hall, Platt, & Hall, 1999). However, in particular, unemployment is a life situation that repeatedly has been linked to suicide attempts and death by suicide. Joiner’s (2005) interpersonal theory of suicide posits that unemployment confers suicide risk at least partly because of individuals experiencing an increased sense of themselves as a burden on others. Other losses that can increase risk include (a) status loss, (b) loss of a loved one, (c) loss of physical health or mobility, (d) loss of a pet loss, and (e) loss of face through recent shameful events (Beghi & Rosenbaum, 2010; Packman, Marlitt, Bongar, & Pennuto, 2004).

Sexual Orientation

Over the years the data have been mixed regarding whether gay, lesbian, bisexual, or transgender individuals constitute a high suicide risk group. More recently, a 2011 publication in the Journal of Homosexuality reported there is no clear and convincing evidence that GLBT individuals die by suicide at a rate greater than the general population (Haas et al., 2011).
Although this is good news, the data also show that GLB populations have significantly higher suicide attempt rates. Haas et al (2011) wrote:

Since the early 1990s, population-based surveys of U.S. adolescents that have included questions about sexual orientation have consistently found rates of reported suicide attempts to be two to seven times higher in high school students who identify as LGB, compared to those who describe themselves as heterosexual. (p. 17)

Overall, it’s likely that transgender people and youth questioning their sexuality may be at increased risk for suicide attempts or death by suicide. Additionally, GLBT youth who have experienced homosexual-related verbal abuse and parental rejection for their behaviors related to gender and sexuality are more likely to engage in suicidal behaviors (D’augelli et al., 2005).

In conclusion, as you can probably see from this and the two previous posts, there are many complex and potentially interacting factors associated with increased suicide risk, but no great predictors. This is unfortunate for those of us who would like to use prediction methods to prevent and reduce suicide rates. But, at the same time, the fact that many people who experience great suffering in their lives still choose life, is a testament to human strength and resiliency.

And, speaking of resiliency, maybe I’ll be focusing on an exciting and upbeat topic like that next time. Until then, I wish you all the best in your efforts to help your clients through difficult times in their lives. Your work may be more important than you think.