Attached to this post are the handouts from the May 1 “Tough Kids, Cool Counseling” workshop in Spearfish, South Dakota.
It was a great day with about 85 wonderful, amazing, and exceptionally nice school and mental health counselors from throughout South Dakota.
This is the powerpoint:
SDMHCA Workshop 14 Part No Cartoons
And this is the supplementary handout:
SDMHCA TKCC Part II Supplement
I hope this information is helpful!
John SF
Below are two items. The first is the powerpoint file for the South Dakota Counseling Association keynote on May 2. The second is the summary handout that goes with the keynote.
Confirmation bias is an insidious cognitive process that typically travels just below our awareness. Here’s how it worked for me today.
I’m on my way to Spearfish, SD to do a “Tough Kids, Cool Counseling” workshop tomorrow and keynote on Friday. My belief is that it’s always hard to pack up and get everything ready and make it to the airport. Usually I hold a negative confirmation bias in my mind. This negative bias involves a belief or working hypothesis that the world will conspire against me and stress me out in the process of trying to arrive at the airport in a timely manner.
First, I’m in my office and about to turn off my computer and my office phone rings. Rarely does my phone ring anymore and it’s even more rare that I answer it with only 10 minutes left before my pre-planned office departure time. But my impulses take over and I answer it. It’s the associate dean and our development officer wondering if I have a few minutes to talk. They rush down and we meet for a few minutes, which puts me only slightly behind as I head to the copy machine for, of course, some last minute copies.
Second, Rita is driving me to the airport. She asks me what route she should take (please note: Rita almost never asks ME what route to take and so this is an anomaly in and of itself). I rise to the bait and tell her my quickest route to the airport.
Third, my best route to the airport begins crumbling when we have to stop for a train.
Fourth, my best route has a back-up option in case of a train. We take it. It leads us directly into road construction.
Fifth, we circumnavigate (I love that word) the road construction and make it to the airport.
Sixth, my confirmation number is in a “pre-check-in” email on my cell phone. I pull out my phone and sort through 53 emails, twice, before concluding that it has apparently disappeared.
Seventh, I get checked in anyway and head through security and upstairs only to discover that Liquid Planet’s espresso machine is broken and I can’t have my pre-flight white chocolate mocha and . . .
Eighth, I have to drag my bags and myself downstairs to use the restroom because the road construction has taken over the upstairs airport bathroom.
But now I’m here, sitting and waiting to board my flight and marveling at how today, for some odd reason, I was able to monitor the universe’s push-back and yet not get sucked into a bad mood. Of course, given that I saw the confirmation bias coming, I was able to simultaneously notice the universe’s positive encouragement as well. After all:
1. The associate dean and development officer are two of the nicest people on the planet and they wanted me to speak at a fancy College of Education and Human Sciences event and that sounds like fun.
2. The copy machine worked perfectly and there was NO LINE!
3. It was a beautiful, sunny day in Missoula as I bicycled back and forth from the University on my perfectly functional bike that didn’t get a flat tire.
4. Rita shared half an avocado with me while at home.
5. The toilet flushed without incident.
6. The car started without incident.
7. The circumnavigation went well and it reminded me of how much I like the word circumnavigation. I was also reminded that Rita is an excellent driver and stupendous conversationalist.
8. The guy at the United Airlines desk was nice and efficient.
9. I got to be in the TSA pre-screening category (not that it makes any difference in the Missoula airport).
10. Instead of getting a white chocolate mocha that I didn’t need I got exercise on my way to and from the restroom.
11. I still got here in time to write this post.
12. And, I’m on my way to Spearfish, South Dakota to have an excellent time with some cool professionals who have dedicated their lives to helping others.
Seriously, it would be difficulty to conclude, despite my usual negative confirmation bias about trips to the airport, that this day (and perhaps my whole life) is anything other than infused with most excellent good fortune.
I wish you all the best with your own confirmation bias challenges. Your homework assignment is to intentionally count the positive events in your life and intentionally not count or dwell too much on the less-positive events.
Yesterday and today it’s been excellent being back in Portland and taking in the fabulous spring showers. To make things even better, I’ve been at the National Parenting Education Network (NPEN) annual meeting along with an interesting mix of people who are immensely dedicated to helping and supporting parents. It’s hard to get any better than that, but to add even more frosting to the cake (I use this only metaphorically because I’m not really a frosting fan), I got to be here with Chelsea and Nora and Rita and . . . even Waganesh!
Here’s NPEN’s Vision Statement: The vision of the National Parenting Education Network (NPEN) is that all parents/families will have the information, resources and support needed to provide a nurturing relationship and an optimal environment that will encourage their children’s healthy growth and development.
What still surprises me is that very few people seem to understand the deep importance of parenting and even fewer seem to know about NPEN. Just in case you don’t know about NPEN, here’s the website address: http://npen.org/
In this coming year, NPEN will be turning the corner and beginning to incorporate and post original content on it’s website. You can become a member (it’s cheap, only $25) and join the listserv. Additionally, at some point in late summer or early fall, Sara Polanchek and I, along with the many experts and parents associated with NPEN, will be launching a series of parenting podcasts underwritten by the fabulous Engelhard Foundation. So . . . be watching for that.
In the meantime, tomorrow night Families First Missoula is having a fundraiser. Check it out here: https://www.childrensmuseummissoula.org/events/go-mad-spring-soiree/
And FF Missoula asked me to write a short parenting philosophy. . . and so here’s that: Parenting is a balance of many things; it includes balancing joy and disappointment and love as well as anger. This makes consistently parenting well an immense challenge. Perhaps the biggest parenting challenge of all involves being able to simultaneously set limits while communicating empathy. This is difficult because often children need (but don’t want) their parents to be an authority—and it’s easy for parents to become too authoritarian and consequently lose the ability to respond empathically to their children’s developing emotional struggles.
And finally, here’s a photo of my two daughters engaging in the balance of conducting some sort of smell check with each other. Don’t ask me why.
Strategies for Parenting Teens: A Brief Parenting Workshop [This is a handout from an old parenting workshop from way back in my Families First days.]
I. Introduction
II. Opening Stories: Dealing with Yourself First
1. How will you stay calm? The answer to this question is surprisingly simple. Managing emotions doesn’t require years of psychotherapy. It requires the following components.
2. A plan for dealing with your anger/emotions.
3. Rehearsing and practicing of the plan repeatedly, before, during, and after you face situations that trigger your anger.
III. Amazing Parenting Strategies
A. Adopt a New Best Attitude: There is one attitude that, if you’re able to adopt it, will help you respond in a more constructive way to all children. I know it sounds absolutely crazy, but, here it is:
LOOK FORWARD TO THE NEXT TIME YOUR TEEN HAS AN OUTBURST OR TEMPER TANTRUM . . . BECAUSE
1. If you look forward to teen’s outbursts, you’ll be able to deal with them in a more positive and graceful way.
2. If you look forward to teen’s outbursts, you can use them as an opportunity for emotional education.
3. If you look forward to teen’s outbursts, you can use them as an opportunity for greater intimacy. Think about the nightmare analogy.
B. Approach Teens Gently, Empathically, and With The Desire to Comfort Them: Being a teenager sucks. If you recall, your body is in turmoil, everybody is staring at you, and your friends are inconsistent and judgmental. Therefore, we should try to be the sort of parent who is a pillar of strength and support and not a big source of criticism and punishment.
C. Use Boring Punishment: Often we get this backwards and end up yelling at our kids, rather than making the punishment boring. Behavior modification principles suggest that we should be exciting when delivering praise or rewards.
D. Get Curious, Not Furious. Just like in the children’s story about the lion and the mouse, there will almost always be some form of distress under teen’s anger or agitation. As you approach gently, with your new positive attitude, think about what might be underneath your teen’s anger. Is she hurt? Is he upset about not getting what he wants? Is she trying to manipulate you into getting what she wants? Is he just blowing off steam?
E. It IS possible to have both empathy for your teen’s feelings AND to set limits on his/her behavior. For example, you can say, “I can see you’re very upset because you can’t go out tonight.” This statement contains both empathy AND a statement of the limit that you’re setting. Many teens throw tantrums to obtain power and control. Therefore, you should always abide by the following rule:
IF A TEEN IS BEHAVING AGGRESSIVELY OR OBNOXIOUSLY, THE ANSWER IS ALWAYS – NO!
F. Use Encouragement: Praise is a great tool for shaping your teen’s behavior, but try to avoid relying exclusively on praise . . . instead, try using encouragement. For example, after your child handles a difficult situation gracefully, instead of saying, “That was great” try saying, “I noticed you kept your cool.” The magic of encouragement occurs because, by not giving specific praise, you give your child the opportunity to conclude himself or herself that the behavior you noticed was good. And often it’s more important for your child to evaluate his/her own behavior than to always have to look to you for approval or praise. Character feedback is another form of encouragement.
G. Use Grandma’s Rule: This strategy involves using the language, “When You, Then You.” For example, you might say, after having empathy for your child’s upset feelings, “When you calm down, then we can get ready to go to the park.” The key to this strategy is to keep your language perfectly clear.
H. Use Mutual Problem-Solving: Too often parents feel like it’s totally their responsibility to solve their child’s problems. This involves unilateral problem-solving and it doesn’t really teach your teen anything but that she/he should rely on you. Instead, try engaging your child in mutual problem-solving.
IV. Looking to the Future: Four Key Questions
To make sure you’re staying focused and effective, it helps to ask yourself the following four questions (from Choice Theory – William Glasser and Robert Wubbolding).
A. What do you want?
B. What are you doing?
C. Is it working?
D. Should you make a new plan?
For more detailed information on these and other parenting strategies, go to: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_8?s=books&ie=UTF8&qid=1397876334&sr=1-8
It’s that time of the year (at most colleges and universities) when those of us doing and supervising counseling and psychotherapy should be thinking about how to handle termination. Well, actually we should have been thinking about it before, but if not then, now is good.
Anyway, I just sent the following termination checklist out to my MA and Doc students here at U of MT and thought this could be helpful for others, so here it is. Keep in mind that it was written for working with youth, but can be modified to stimulate your thinking about termination with whatever population with which you work.
Termination Content Checklist
[Adapted from Sommers-Flanagan, J., and Sommers-Flanagan, R., (2007).
Tough Kids, Cool Counseling: User-Friendly Approaches with Challenging Youth.
Alexandria, VA: American Counseling Association]
The following termination content checklist may be helpful for you as you plan for counseling or plan for termination. Keep in mind that this is not a comprehensive checklist that you MUST complete at the end of counseling. Also, keep in mind that the sample statements are just samples and that you should find your own words for expressing these (or similar) things. The point is that this is a guide to help you think about termination—even though some of the details will be different for you and your client(s).
_____ 1. At the outset and throughout counseling, the counselor identifies progress toward termination (e.g., “Before our meeting today, I noticed we have 4 more sessions left,” or “You are doing so well at home, at school, and with your friends. . . let’s talk about how much longer you’ll want or need to come for counseling”).
_____ 2. The counselor reminisces about early sessions or the first time counselor and client met. For example: “I remember something you said when we first met, you said: ‘there’s no way in hell I’m gonna talk with you about anything important.’ Remember that? I have it right here in my notes. You were sure excited about coming for counseling” (said with empathic sarcasm).
_____ 3. The counselor identifies positive behavior, attitude, and/or emotional changes. This is part of the process of providing feedback regarding problem resolution and goal attainment: “I’ve noticed something about you that has changed. It used to be that you wouldn’t let adults get chummy with you. And you wouldn’t accept compliments from adults. Now, from what you and your parents tell me and from how you act in here, it’s obvious that you give adults a chance. You aren’t always automatically nasty to every adult you see. I think that’s nice.”
_____ 4. Acknowledge that the relationship is ending with counseling termination: “Next session will be our last session. I guess there’s a chance we might see each other sometime, at the mall or somewhere. If we see each other, I hope it’s okay for us to say hello. But I want you to know that I’ll wait for you to say hello first. And of course, I won’t say anything about you having been in counseling.”
_____ 5. Identify a positive personal attribute that you noticed during counseling. This should be a personal characteristic separate from goals the client may have attained: “From the beginning I’ve always enjoyed your sense of humor. You’re really creative and really funny, but you can be serious too. Thanks for letting me see both those sides. It took courage for you to seriously tell me how you really feel about your mom.”
_____ 6. If there’s unfinished business (and there always will be) provide encouragement for continued work and personal growth: “Of course, your life isn’t perfect, but I have confidence that you’ll keep working on communicating well with your sister and those other things we’ve been talking about.” You may want to explicitly describe how your client doesn’t “need” counseling, but that continued counseling or counseling in the future might be helpful: “You know some people come to counseling to work on big problems; other people come because they find counseling can be useful and help them move toward personal growth or greater awareness; and other people just like counseling. You might decide you want to continue in counseling or start up again for any of these reasons.”
_____ 7. Provide opportunities for feedback to you: “I’d like to hear from you. What did you think was most helpful about coming to counseling? What did you think was least helpful?” You can add to this any genuine statements about things you wish you’d done differently as long as it’s not based on new insights. For example, if your client got angry for you for misunderstanding something and this was processed earlier, you might say: “And of course I wish I had heard you correctly and understood you the first time around on that [issue], but I’m glad we were able to talk through it and keep working together.”
_____ 8. If it’s possible, let the client know that he or she may return for counseling in the future: “I hope you know you can come back for a meeting sometime in the future if you want or need to.”
_____ 9. Make a statement about your hope for the client’s positive future: “I’ll be thinking of you and hoping that things work out for the best. Of course, like I said in the beginning, I’m hoping you get what you want out of life, just as long as it’s legal and healthy.”
_____ 10. As needed, listen to and discuss client wishes about continuing counseling forever or client wishes about transforming their relationship with you from one of counselor–client to that of parent–child or friend: “Like you’ve known all along, counseling is kind of weird. It’s not like we’re mom and daughter or aunt and niece. And even though I like you and feel close to you, it isn’t really the same as being friends” (further discussion and processing of feelings follows).
For more information on termination with youth, go to: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_3?s=books&ie=UTF8&qid=1396895008&sr=1-3
Aloha from Honolulu. This week Rita and I have been working from Honolulu, Hawaii as we attend and present at the annual convention of the American Counseling Association. Yesterday we presented on how counselors can integrate evidence-based relationships into the first interview. This is mostly based on John Norcross’s excellent work on evidence-based relationships. After the presentation one attendee asked if I could send him a copy of an intake interview outline. . . and so I’m posting a brief intake interview outline and an associated classroom activity below.
More on Highlights from Honolulu soon. But here’s an intake outline for now. This is from the Clinical Interviewing text, but you should keep in mind that the Clinical Interviewing text also includes a more extensive outline. See: http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=la_B0030LK6NM_1_1?s=books&ie=UTF8&qid=1396163487&sr=1-1
A Brief Intake Checklist
When necessary, the following topics may be covered quickly and efficiently within a time-limited model.
______ 1. Obtain presession or registration information from the client in a sensitive manner. Specifically, explain: “This background information will help us provide you with services more efficiently.”
______ 2. Inform clients of session time limits at the beginning of their session. This information can also be provided on the registration materials. All policy information, as well as informed consent forms, should be provided to clients prior to meeting with their therapist.
______ 3. Allow clients a brief time period (not more than 10 minutes) to introduce themselves and their problems to you. Begin asking specific diagnostic questions toward the 10-minute mark, if not before.
______ 4. Summarize clients’ major problem (and sometimes a secondary problem) back to them. Obtain agreement from them that they would like to work on their primary problem area.
______ 5. Help clients reframe their primary problem into a realistic long-term goal.
______ 6. Briefly identify how long clients have had their particular problem. Also, ask for a review of how they have tried to remediate their problem (e.g., what approaches have been used previously).
______ 7. Identify problem antecedents and consequences, but also ask clients about problem exceptions. For example: “Tell me about times when your problem isn’t occurring. What happens that helps you eliminate the problem at those times?”
______ 8. Tell clients that their personal history is important to you, but that there is obviously not time available to explore their past. Instead, ask them to tell you two or three critical events that they believe you should know about them. Also, ask them about (a) sexual abuse, (b) physical abuse, (c) traumatic experiences, (d) suicide attempts, (e) episodes of violent behavior or loss of personal control, (f) brain injuries or pertinent medical problems, and (g) current suicidal or homicidal impulses.
______ 9. If you will be conducting ongoing counseling, you may ask clients to write a brief (two- to three-page) autobiography.
______ 10. Emphasize goals and solutions rather than problems and causes.
______ 11. Give clients a homework assignment to be completed before they return for another session. This may include behavioral or cognitive self-monitoring or a solution-oriented exception assignment.
______ 12. After the initial session, write up a treatment plan that clients can sign at the beginning of the second session.
Prompting Clients to Stick With Essential Information
Using the limited-session intake-interviewing checklist provided in Table 7.2, work with a partner from class to streamline your intake interviewing skills. Therapists working in a managed care environment must stay focused and goal-directed throughout the intake interview. To maintain this crucial focus, it may be helpful to:
1. Inform your client in advance that you have only a limited amount of time and therefore must stick to essential issues or key factors.
2. If your client drifts into some less-essential area, gently redirect him or her by saying something such as:
“You know, I’d like to hear more about what your mother thinks about global warming (or whatever issue is being discussed), but because our time is limited, I’m going to ask you a different set of questions. Between this meeting and our next meeting, I want you to write me an autobiography—maybe a couple of pages about your personal history and experiences that have shaped your life. If you want, you can include some information about your mom in your autobiography and get it to me before our next session.”
Often, clients are willing to talk about particular issues at great length, but when asked to write about those issues, they’re much more succinct.
Overall, the key point is to politely prompt clients to only discuss essential and highly relevant information about themselves. Either before or after practicing this activity with your partner, see how many gentle prompts you can develop to facilitate managed care intake interviewing procedures.
Being in the middle of March Madness is an excellent moment to step back to briefly reflect on the nature and function hype and hyperbole. Let’s start with a look at madness.
Madness is a 14th century term for insanity and insanity implies a break from reality. As such, March Madness is aptly named. For many (including me) March Madness is a good time to ignore reality, job productivity, and common sense. Filling out brackets and imagining that you might correctly pick every winner and win a billion dollars is a great example of taking a break from reality.
Below is a quick Q & A about some of the main things that are wrong (or insane) about March Madness
Question #1: Who will win the NCAA basketball tournament?
The winner of the NCAA tournament will be (surprise) the NCAA and all rich folks who stand to get richer based on their associations with the NCAA. This includes a certain wealthy man whom I’ll refer to as “he-who-will-not-be-named,” NCAA sponsors, CBS, and Vegas. It will also include one team with a rich coach who makes more than $2,000,000 a year and a roster of about 15 relatively poor guys who make hardly anything (but one or two of which will make bank next year). My point is that you shouldn’t confuse March Madness with a charity benefit. This tournament is designed to do that good old American thing of helping the rich get richer while the rest of us take a break from reality and experience entertainment.
Question #2: Who will be the losers?
Nearly everyone else will be the losers. Last year, Harvard Business Review estimated the cost of the NCAA tournament in losses to worker productivity to be from $175 million to $1 billion. There also will be 67 teams (not to mention the non-qualifiers) who will be admirably labelled losers. In addition, even the winners (players who have spent substantial time and effort working and playing together) will be generally uncompensated.
Question #3: Seriously, who should I bet on?
First thoughts on this: (a) Bet on the home team; (b) bet on the East coast; and (c) bet on the favorites (aka: the big names). Even though the NCAA tournament is played at neutral sites, like most things NCAA, this is only partly true. This year, we have Florida in Florida, Duke in Raleigh, NC, Wisconsin in Wisconsin, and Kansas in far off St. Louis, Missouri. Of course, this doesn’t always work out (think Duke), but it’s a good start. Also, NCAA basketball nearly always tilts Eastward. This is related to ESPN’s contractual preference for Eastern conferences (and efforts to ignore the left coast). Finally, come crunch time, the big name players and coaches will get the call (or non-call) from the officials. In the end, when it comes to NCAA basketball, the refs appear unable to help themselves from favoring the favorites.
Question #4: Who will be the winning coach?
When in doubt, it makes sense to tip your hat to whoever has the most resources. Consequently, consider what the following well-dressed coaches make annually (and compare it to what their players and college/university presidents and professors make) and then go with the resource rich . . . because this is America, where the rich are usually favored in the lottery of who gets richer.
Based on the preceding list, it looks to be a good year for the Big Ten. Or a bad year, if they spend all that money and come up with what I think they’ll come up with.
Question #5: Who will win the sportsmanship award?
Of course, there is NO sportsmanship award, but if there was one, I’d give it to all the players and coaches who display fabulous restraint despite exposure to stupefying heckling fans and enigmatic basketball officiating. They will rarely complain. They won’t storm the stands to try to shut the mouths of fans who should be arrested for what they say. They will just politely take all the crap aimed their direction. Seriously, the players are 18 to 23-year-olds and they show WAY more maturity than we should expect . . . which is why college basketball really needs to do something to protect them from the fans and the officials.
Question #6: How can you make yourself even more insane?
The is simple: just read any of a bevy of sports message boards on the Internet. If you read these you’ll be exposed to perhaps the most inane and ridiculous commentary on the face of the planet. My advice: Just say no to reading the message (comment) boards. I’ve done it and nearly always instantly regret the effect it has on my mental health.
Question #7: Why all the upsets?
There will be upsets because there are always upsets and we know from decades of tightly controlled psychological research that the best predictor of the future is the past. We also know that the only thing people can really predict is the past . . . which is why I’ll be submitting my Billion dollar bracket right after the tourney ends.
The other reason we know there will be upsets is because most members of the NCAA selection committee can’t see very far past the three letters they’ve scrawled right next to their navels. These letters are R-P-I. You probably know that RPI stands for ratings percentage index. What you may not know is that the RPI is seriously flawed. I mean seriously. That’s why the 12 seeds nearly always beat the 5 seeds. And did anyone really think that UMASS was a 6 seed or Duke a 3 seed or Ohio State (5-4 in their last nine games) deserved a 6 seed? The RPI is a bogus statistical procedure that tends to help teams from BIG conferences with more money. Unfortunately, odds-makers at Vegas could do a better job at seeding the NCAA tournament than the selection committee.
Question #8: Why didn’t anyone win the Billion dollars
“He who will not be named” did a big promotion of temporary March insanity when he offered one Billion dollars for a perfect bracket. This was such a scam that. . . hahaha. . . you could almost hear the evil laugh. Like most scams, this was just a publicity stunt. You would have better odds of winning two back-to-back powerball lotteries with two single tickets than the Billion dollars of “He who won’t be named.” If you really thought you could win, then, although I’m generally against psychotropic medications, I would recommend Lithium. This is all really too bad because I used to respect the man I won’t be naming.
Okay. Let me end with an apology. I would have started with an apology but the great author Henry James said you should never start a letter with an apology. So here’s my closing apology: Sorry for going all negative. I love college basketball. I just hate the fans, the refs, the selection committee, and the unequal distribution of the wealth and glory. Besides, my bracket got busted, so I’m in an insanely bad mood.
Listening in psychotherapy and counseling is partly art and partly science. This week I have the good fortune of having a blog piece I wrote on Listening as Meditation published at psychotherapy.net. You can access this blog piece — and other excellent psychotherapy.net blog pieces — at: http://www.psychotherapy.net/blog
Have an excellent and mindful Wednesday.
John SF
A Description of the Six Column CBT Technique
In contrast to popular belief, CBT requires counselors to be warm and compassionate. Also, the focus of CBT is on experiential psychoeducation. Aaron Beck emphasized collaborative empiricism. Never forget that term. Collaborative empiricism is the bedrock of good CBT. It emphasizes the process of counselors and clients working together to test the accuracy and usefulness of specific thoughts and behaviors. As a therapeutic process, collaborative empiricism is also central to Person-Centered and Motivational Interviewing approaches. Remember: We want the client to have a central role in determining the usefulness and dysfunctionality of his or her cognitions and behaviors.
The six column technique is simply a procedure that helps clients and counselors organize, explore, and discover how situations, thoughts/beliefs, emotions, behaviors, and emotional/interpersonal/psychological outcomes are inter-related. This is my own particular version of the six column technique. It’s derived from the work of Aaron Beck, Albert Ellis, Judith Beck, and other cognitive behavioral therapists. You can see a short clip of me using this technique at: https://www.youtube.com/watch?v=jfVeeGJHFjA
Here’s a description of the six columns:
Column #1: The Situation
BE THINKING ABOUT LINKING EMOTIONS TO SPECIFIC SITUATIONS
It may be that you’ll begin with whatever emotional distress the client is experiencing or reporting. Or you may begin with thoughts and beliefs that are clearly linked to specific client emotions and behaviors. Or you may begin with the situation or “trigger” for the cognitions and subsequent emotions.
Here’s an example of a situation as reported by a client:
“My in laws are staying in my home .”
“They’re messy and lazy and I have to pick up after them”
Column #2: Automatic Thoughts and Automatic Behaviors
HELP CLIENTS SEE THAT AUTOMATIC THOUGHTS ARE OFTEN THE BRIDGE BETWEEN SITUATIONS AND EMOTIONS
Here are some examples of the automatic thoughts the clients thinks when she faces the previously described situation:
“They’re old enough to pick up after themselves.”
“Sometimes I stand in front of the television they’re watching to block their view as I pick their stuff up.”
Sometimes if “she” says she’ll do the dishes, I say, “No thanks. I want them to get done in the next two weeks.”
REMEMBER THAT AN EXPLORATION OF YOUR CLIENTS AUTOMATIC THOUGHTS AND BEHAVIORS OFTEN WILL SHED LIGHT ON DEEPER CORE BELIEFS ABOUT THE SELF, THE WORLD, AND THE FUTURE.
Column #3: Emotions and Sensations
SOMETIMES IT IS VERY NATURAL TO START HERE BECAUSE YOUR CLIENT’S EMOTIONS AND SENSATIONS MAY BE A WAY THAT THE MIND AND BODY ARE VOICING HIS OR HER DISTRESS (or you may find the best entry point into the six column technique is somewhere else)
Here are the ratings and descriptions the client provided for column #3:
Anger = 75 (on a 0-100 scale with 0 = totally mellow and 100 = explosive distress)
Discomfort = 75
EMOTIONS AND SENSATIONS MAY BE WHAT IS MOST TROUBLING TO CLIENTS AND THAT’S WHY THEY’RE TYPICALLY RE-EXAMINED IN COLUMN #6: NEW OUTCOMES
Column #4: Helpful Thoughts
HELPFUL THOUGHTS ARE ALSO SOMETIMES REFERRED TO AS “COOL THOUGHTS.” THIS IS ESPECIALLY TRUE WHEN WORKING WITH ANGER AND AGGRESSION BECAUSE COOL THOUGHTS HELP CALM OR COOL OFF THE ANGER AND REDUCE THE POTENTIAL FOR AGGRESSION.
Here are some thoughts that the client identified as helpful. Helpful thoughts are often seen as adaptive or more accurate or more “rational” (which is an Albert Ellis term).
“This is important for my husband.”
“I can see this as a challenge for me to become more direct and assertive.”
“They mean well.”
A WAY OF ASKING ABOUT HELPFUL THOUGHTS IS TO JUST ASK DIRECTLY: WHAT ARE SOME THOUGHTS OR BELIEFS THAT YOU THINK WOULD BE HELPFUL TO YOU IN THIS SITUATION? YOU MAY NEED TO HELP CLIENTS WITH THIS BY PROVIDING EXAMPLES . . . BUT NOT BY TELLING THEM WHAT THEY SHOULD THINK. ENCOURAGE THEM TO FIND THEIR OWN WORDS.
Column #5: Helpful Behaviors
SIMILAR TO THE PRECEDING COLUMN, WE CAN THINK OF BEHAVIORS AS “HOT” OR “COOL” BEHAVIORS. HOT BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS WORSE; COOL BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS BETTER.
Here are some behaviors the clients said she thought might be helpful:
“I could sit down and talk with them about picking up their messes at a regular time.”
“I could ask my husband to talk with them.”
“I could go to a Yoga class two nights a week.”
WHEN IT COMES TO BOTH HELPFUL THOUGHTS AND HELPFUL BEHAVIORS, IT’S USEFUL TO THINK OF THEM AS OCCURRING (A) BEFORE, (B) DURING, OR (c) AFTER THE SITUATION ARISES. SOME BEHAVIORS (E.G., GETTING ENOUGH SLEEP) HELP THE SITUATION AS A PROACTIVE OR PREVENTATIVE ACTION. OTHER BEHAVIORS (E.G., DEEP BREATHING) MAY BE CRUCIAL DURING THE SITUATION. STILL OTHER BEHAVIORS (E.G., VENTING TO A FRIEND OR PROVIDING SELF-REINFORCEMENT) MAY BE HELPFUL AFTER THE SITUATION IS OVER.
Column #6: New Outcomes
AFTER IMPLEMENTING THE HELPFUL COGNITIONS AND HELPFUL BEHAVIORS, IT’S A GOOD IDEA TO RE-EVALUATE THE CLIENT’S EMOTIONS AND SENSATIONS (OR DISTRESS).
In this case, the client provided the following ratings:
Anger = 40
Discomfort = 40
ONE OF THE GOALS OF CBT IS TO REDUCE DISTRESS AND REDUCE SYMPTOMS AND MAKE LIFE A LITTLE BETTER. YOU MAY NOT CREATE VAST IMPROVEMENTS, BUT IMPROVEMENTS ARE IMPROVEMENTS. THIS IS ALSO JUST THE BEGINNING OF CBT (OR WHATEVER APPROACH YOU’RE USING) BECAUSE THE WHOLE POINT IS THAT LIFE IS AN EXPERIMENT AND THAT WE COLLABORATIVELY AND INTERACTIVELY ARE HELPING CLIENTS TRY OUT NEW THOUGHTS AND BEHAVIORS THAT MAY (OR MAY NOT) LEAD TO IMPROVEMENT. AND IF THE IMPROVEMENT ISN’T OPTIMAL . . . THE CBT WAY IS TO GO BACK TO THE BEGINNING AND REWORK THE PROCESS TO SEE IF FURTHER IMPROVEMENTS CAN OCCUR.
CBT Tips
Here are a few tips on how to integrate CBT in your work.
Some counselors or mental health professionals resist using CBT and complain that it’s too sterile or too educational or not focused enough on feelings. Basically, I think this is a cop-out similar to CBT folks who say that person-centered therapy is ineffective. My belief (and I think it’s rational and so it must be (smiley face) is that when mental health professionals don’t understand how to implement a particular approach, they blame the approach rather than admitting their lack of knowledge or skill. Instead, I encourage you to try this six column CBT model, but use it with whatever other model you prefer. In other words, you can be a person-centered CBT person or an existential CBT person . . . especially if you just use this six column technique as a means for exploring and understanding different dimensions of your client’s personal experience.
Goal-setting is essential to counseling. From the CBT perspective, goal-setting is initiated by generating a problem list. However, your IR clients may not have a problem listJ. That’s why you may need to use your excellent active listening skills to help your clients focus in on a distressing emotion. Then you can begin with the distressing or disturbing emotion and build the six columns from there.
Good CBT involves adopting an experimental mindset (never forget collaborative empiricism). All you’re doing is helping your client look at his/her daily experiences and identify patterns. It helps to organize the client’s experience into Situation, Automatic Thoughts/Behaviors, Emotions and Sensations, Helpful (Cool) Thoughts, Helpful (Cool) Behaviors, and New Outcomes. You can explore these common dimensions of human experience collaboratively.
It’s very important to know and remember that giving behavioral assignments can be disastrous. This is part of why a good CBT counselor is better than a technician. If you’re brainstorming possible helpful behaviors, your client (and you) may zero in on a behavior that, if enacted, has a strong possibility of a negative outcome. New behaviors expose clients to risk. The risk may be worth it; but there also may be too much risk.
Avoid asking questions like: “Have you thought about talking directly to your in-laws?” This sort of question implies that your client should talk directly to the in-laws. It’s better to step back and brainstorm behavioral options with your client. Then, emphasize that behavioral goals must always be in the client’s control. Then, after your nice list of behavioral options has been generated, you can look at the different options and engage in “consequential thinking.” In other words, you ask your client to explore the possibilities of what is likely to happen if: “You (the client) directly confront the in-laws about their messy behaviors? “ (See sample six column worksheet).
There are many ways you can get to your client’s underlying core beliefs or cognitive dynamics. For example, you could ask: “What stops you from telling them to pick up after themselves?” The client might respond with a different emotion and new content (e.g., I’m afraid of getting into a conflict). You can pursue this further: “What is it about being in conflict makes it scary?” She might say, “I’m afraid my husband will side with them and leave me.” As a consequence, this conflict is viewed as something she needs to manage independently and gets at a deeper schema: “I must keep the peace and deal with everything or bad things (e.g., abandonment) will happen.” There are two problems with this: (a) If she overfunctions she feels angry and acts passive-aggressively; and (b) there may be truth to this schema/belief. This is why we can’t just push her into being assertive. We must always keep the corrective emotional experience rule in mind. New behavioral opportunities need to be free from the likelihood of re-traumatization.
John Sommers-Flanagan 