All posts by johnsommersflanagan

Personal Reflections, Writing

On Being or Becoming a Writer (Again)

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While I was taking notes on Mary Pipher’s “Writing to Change the World” book, a bug flew in my eye. It was at the precise moment I was typing the following quotation: “When we equivocate we lose an opportunity to build our identities as writers. If you are not doing it already, I advise you to learn to say you are a writer” (p. 76).

Shall I really say “I am a writer!” even if it doesn’t feel quite right?

Or should I be more honest and describe the complete situation by saying, “I am a writer who is trying to write, but I have a bug that just flew in my eye and that’s making it more difficult than it might otherwise be.”

Didn’t someone once say that honesty is the best policy? And isn’t there a story about George Washington honestly confessing that he chopped down a cherry tree that he had no particular business chopping down. Of course that story is a lie and as it turns out Betsy Ross didn’t really sew the first American flag, but she had some fairly effective promotional people who either thought she did or decided to lie on her behalf.

What if I just tell a microscopic white lie to myself? Is that a problem?

Or maybe I just need an agent who will lie willy-nilly on my behalf? I’ve sort of always wanted somebody who would do something will-nilly just for me.

After all, honesty will only take you so far and the only advice my father gave me about being married was that “You don’t have to always tell your wife EVERYTHING you’re thinking.” That’s good advice, except that it contradicts with what Carl Rogers said about maintaining a transparent relationship and how he learned the most from being completely honest with his wife about the things that were most difficult to talk about.

Wouldn’t it be true, however (this, I understand, is how attorneys like to begin questioning the person who has just taken the stand), that lying destroys relationships and can take you to prison where you might share a cell with Piper Kerman. Then again, she wrote a book (Orange is the New Black) that got made into a television show and that’s pretty cool.

It’s very difficult to find clean and straight answers upon which everyone agrees. I’ve noticed this and thought I should honestly articulate this observation.

When I’m doing counseling with young people who have anger problems or who are cutting or who are embracing a negative and unhelpful identity, I sometimes ask them to consider thinking differently about themselves. The technique is a little bit of a knock off of Alfred Adler’s Acting As-If. I don’t ask them to pretend or to tell themselves bald-faced lies, but instead to tell more of the complete hairy-faced narrative truth. For example, when a girl tells me she’s got a “terrible temper,” I suggest and implore and encourage her to capture the WHOLE DARN NARRATIVE and instead tell herself something like, “I believe I’ve had a terrible temper in the past, but I’m working on it.”

Pipher (not Piper) says I should learn to call myself a writer. Obviously that worked for her and she’s been immensely successful and now she’s sharing it as a writing strategy. But what if that doesn’t work so well for me? What if my mantra is that I’m a writer who’s got a bug in his eye and that darn bug is making it terribly difficult, but I’m working on it?

What if I prefer a different hat style?

Here’s what I like instead: “I am becoming a writer.”

I most definitely like that better. I am becoming is a better fit for my tentative always in flux and change and self-reflective in-moderation identity.

I am becoming a writer.

And I hope you are too.

Personal Reflections, Writing

Professional Writing for Us Professionals Who May Not Quite be Writers . . . Yet

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This past week I’ve been searching in vain for the origin of my favorite pithy advice to aspiring writers. It may have been Flannery O’Connor or George Orwell or another literary-type who noted or shouted or penned the phrase: “Writers write.”

This nice thing about this advice is that it’s simultaneously very general and very specific and very redundant all at the same time.

But there are also different breeds of writers who write.

While I was at the University of Portland, one of my noon-time basketball buddies was a Math professor. When he wasn’t making fun of his own stutter-step dribble or teaching classes or waxing his 1967 Mustang, he was writing a mathematics text. He told me his writing philosophy—which was really more of a strategy, but then he was a math guy. Every night he wrote one page of his textbook. Just one page . . . and he didn’t go to bed until he had completed this nightly homework. He never said, “Writers write.” He just wrote.

Another one of my Portland basketball buddies was an English professor, writer, and poet. He didn’t talk much about writing, probably because he was too busy reaching in and hacking my arms as I tried to shoot. When I asked him how he thought computers had affected writing and writers (this was the late 1980s), he said he thought there was too much cutting and pasting going on. Lines or stanzas or paragraphs would find their way to places where they didn’t belong. He was a real writer; a literary guy; a pen and paper type. He also wrote every day, but he was too interested in the muse to ever start or stop himself on a clock or a page.

This brings me to my point.

In the Department of Counselor Education at the University of Montana, we have a brand new doctoral-level course on advanced research and professional writing. As a caveat, I should note that we make no claim to be real (aka literary) writers. But that won’t stop us from doing what real writers do and following their advice.

We will write . . . every day . . . and not just because writers write, but also because of what the great science fiction writer Ray Bradbury suggested: “Just write every day of your life. Read intensely. Then see what happens. Most of my friends who are put on that diet have very pleasant careers.”

We will see what happens. We would like to have very pleasant careers.

There are many writing genres and styles and venues. It can be confusing. There are blogs and grant proposals and professional journal manuscripts and book chapters and emails and books and magazine articles and personal journals and the letter you should be writing to your mother. There are also many places to publish and many more places for not publishing. Right now I have at least 50 unfinished and unpublished blogs and commentaries and journal article manuscripts and books on my computer. This work is sitting and waiting for renewed inspiration or focus or time. I fear that I’m violating Annie Dillard’s advice on whether to hold ourselves back or break free. She wrote: “Do not hoard what seems good for a later place in the book, or for another book; give it, give it all, give it now.”

Speaking of hoarding, we don’t plan to keep this writing experience all to ourselves. And this brings me to my point (again). All who read these words may participate. Here are two examples of what you can do:

  1. You can read these blogs and provide commentary or critique. For example, shortly after posting the blog, “The Long Road to Eagle Pass Texas” my wife and co-author informed me that I had made a glaring grammatical error. If you read that post and can identify a grammatical error, please offer up your feedback. You can email me directly at john.sf@mso.umt.edu or post on this blog.
  2. You can write a guest blog. Everyone in our real (not virtual) class will have this assignment. As long as the blog focuses on writing or the helping profession or both and you’re open to feedback, please submit. I will assign it to a doctoral student for review and if it makes it into this blog, you can count on an incisive, but perhaps grammatically-challenged introductory comment from me.

In the meantime, just read . . . intensely . . . and write . . . even if only for yourself . . . and struggle with the muse like a wrestler or dancer or whatever metaphor fits best for you here.

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

Reformulating Clinical Depression: The Social-Psycho-Bio Model

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At a 2007 Mind and Life Conference at Emory University, I had the privilege of watching and listening as Charles Nemeroff, M.D., presented a professional paper to His Holiness the Dalai Lama. [As my older daughter would likely say, Dr. Nemeroff is a very fancy biological psychiatrist.] Nemeroff noted, with some authority, that we now know that one-third of all depressive disorders are genetically-based and two-thirds are environmentally-based. Following this statement, Nemeroff continued to discuss the trajectory of “depressive illness,” focusing, in particular, on findings linked to mice with early maternal deprivation and related findings regarding trauma and depression. His conclusion was that, for some individuals (and mice), the brain is changed by early childhood trauma, while for others, the brain seems unaffected. Interestingly, at that point in the conference the Dalai Lama interrupted and there were animated interactions between him and his interpreter. Finally, the interpreter directed a question to Nemeroff, stating something like, “His Holiness is wondering, if two-thirds of depression is caused by human experience and one-third is caused by genetics, but that humans who are genetically predisposed to depression have to have a trauma for the depression to be manifest, then wouldn’t it be true to say that all depression is caused by human experience?” After a brief silence, Nemeroff responded, “Yes. That would be true.”

Most of us have heard about the biopsychosocial model in contemporary medicine. Below I’ve included some information about its origin (this info is adapted from a 2009 Journal of Contemporary Psychotherapy Article; you can find the whole article here: http://www.coping.us/images/Sommers_Campbell_2009_EBP_for_Kids.pdf).

In his 1980 call to medicine, Engel (1980; 1997) encouraged adoption of a biopsychosocial model of health and illness. Despite this recommendation and the increased use of ‘biopsychosocial’ language among non-medical practitioners, medicine has demonstrated little movement toward embracing a biopsychosocial perspective (Alonso, 2004). To some extent, the Nemeroff-Dalai Lama interaction illustrates medical professionals’ tendencies to formulate mental health problems as disease states even when their own data are contradictory. At the Mind and Life Conference, Nemeroff continued to present his illness-based depression formulation even after conceding environmental causality of depression (Nemeroff, 2007).

Although we (Sommers-Flanagan & Campbell) generally advocate medicine’s biopsychosocial model, we see utility in a slightly more radical reconceptualization of depression–especially among youth. This belief rests upon knowledge about the etiology, course, and treatment of depression, equivocal data regarding antidepressant medication effectiveness, potential developmental and medical dangers associated with short- and long-term SSRI use, research on child development and trauma, and our own clinical experience (Sommers-Flanagan & Sommers-Flanagan, 1995a; Sommers-Flanagan & Sommers-Flanagan, 2007). In short, instead of a biopsychosocial model for understanding and treating youth depression, we believe a social-psychological-biological approach is more consistent with current scientific and clinical knowledge.

A Social-Psycho-Bio Model of Clinical Depression

All humans are born into pre-determined social and cultural settings, which directly influence emotional, psychological, social, and biological functioning and development (Christopher, 1996; Sue & Sue, 2013). Although space precludes complete articulation of the social-psycho-bio model, we describe the major components below.

Social-cultural components. Many cultural factors contribute to children’s emotional and psychological development. For example, in the United States, babies are often born to socially isolated mothers living in poverty. These mothers may also be depressed themselves and have little community and governmental support (Goosby, 2007; Knitzer, 2007). In contrast, more communal and supportive cultural settings place less of a parenting burden on individual mothers, thus possibly decreasing depression. It’s likely that different degrees of cultural support to families and children translate into different degrees of relative risk for depressive experiences in children.

Recent research affirms diverging cultural assumptions about depression etiology. Whereas South Asian immigrants viewed depressive symptoms as stemming from social and moral influences (Karasz, 2005), European Americans attributed depression to biological influences. These cultural formulations or expectations likely influence medication or psychotherapeutic efficacy. Although biomedical researchers emphasize genetic contributions to depression, an individual’s depressive predisposition may be strongly influenced by overarching cultural factors. Given Nemeroff’s admission that depression is rooted in human experience, it seems appropriate to us that depression formulations lead with social and cultural, rather than biological factors.

Early caretaker-child interactions. Early caretaker-baby interactions appear to stimulate depression development in very young children. The best example of this comes from studies of maternal depression, which demonstrate that mothers’ depressive behaviors influence their children’s own emotional suffering and other neurological changes (Ashman & Dawson, 2002). This evidence for a direct effect of caregiver behavior on children’s neural activity and possible brain development supports the social-psycho-bio model.

Child trauma. Garbarino’s (2001) statement, “Risk accumulates; opportunity ameliorates” (p. 362) suggests that repeated trauma in the absence of support or opportunity can deeply damage children. Trauma typically occurs within a social and cultural context, and without requisite support and opportunity, it can initiate cognitive, emotional, and social pathology. Sufficiently intense trauma may also produce lasting “psychic scars” (Terr, 1990). Additionally, early childhood trauma drains children and adults of meaningfulness (Garbarino, 2001). There is little doubt about the powerful contribution of trauma to the development of clinical depression and other mental disorders.

Psychological/cognitive development of depressive symptoms. Considerable evidence supports a cognitive model of depression in adults, and to some extent, in adolescents and children (Kazdin & Weisz, 2003). The pioneering work of Aaron Beck (1970) emphasizes that personal experiences lead individuals to acquire specific negative beliefs about themselves, the world, and the future (i.e., the cognitive triad). Although empirical support for the cognitive triad’s contributory and maintenance roles in depression is strong, these belief systems do not rise autonomously within the psyche. Instead, as Beck notes, these deeply ingrained beliefs are learned vis-à-vis interpersonal experiences.

The development of schemata or internal working models. Theorists spanning analytic, neoanalytic, cognitive, and attachment perspectives have proposed concepts that can be described as schemata or internal working models (Ainsworth, 1989; Glasser, 1998; Morehead, 2002; Young, Klosko, & Weishaar, 2003). Although each theoretical perspective articulates the concept somewhat differently, all involve development of a psychological pattern of repetitive automatic beliefs and expectations. These beliefs and expectations, which implicate the self, the world, and others (or objects), generate repetitive behaviors and affect. A cognitive schema or internal working model arises from early social interactions and may contribute to depression and other emotional and behavioral maladies. From a behavioral perspective, depressogenic working models involve early maladaptive reinforcement contingencies, which must be unlearned before one can acquire more adaptive behavior patterns.

Regardless of theoretical orientation, the internal working model concept forms the foundation of many psychological interventions. For example, it clearly underlies CBT and interpersonal therapy (IPT), two evidence-based practices for treating depression in youth (Kazdin & Weisz, 2003). Essentially, internal working models or schemata include internalized early experiences, and they constitute the “psycho” component of the social-psycho-bio model. When positive, adaptive, and healthy early experiences predominate, internalized working models buffer or immunize the individual against stress and trauma. When critical, negative, and maladaptive experiences predominate, schemata can predispose an individual to acute, chronic, or recurrent depressive episodes.

Neurological (brain-based) manifestations of depression. In addition to social, cognitive, emotional, and motivational experiences, current and recent research has identified cortical functioning correlates of depression. These correlates include neurochemical changes and neural activity, which can be observed via Positron Emission Tomography or functional Magnetic Resonance Imaging. Typically, brain imaging studies in animals, youth, and adults are presented as evidence of biomedical or biogenetic causal factors of depression. In the social-psycho-bio model described here, we suggest that neural changes are natural and inevitable correlates of internalized depressive life experiences. Because we are all biological organisms, observable neural changes associated with clinical depression should come as no surprise. It is important to note, however, that brain changes represent a physical phenomenon correlated with depression; these changes may or may not be causative.

Individuals with more extreme, recurrent, or chronic depressive experiences are perhaps more likely to evidence neurochemical states that add to or maintain depression. Again, we view this as a natural biological process. In some circumstances, this state might require a biological agent (or medication) to be used in combination with psychotherapy to facilitate depression recovery.

Our social-psycho-bio model advocacy does not exclude biomedical contributors to depression. Instead, it identifies biological manifestations as correlates of social and psychological dimensions of depression. This argument has been articulated before, but without much success. We attribute the failure of this view to the din of medication marketing and a cultural orientation toward quick fixes. In fact, we are all biological creatures with intricately interconnected brains characterized by dazzlingly complex electrochemical communication. The search for fMRI and PET scan differences between depressed and non-depressed individuals represents a logical and natural development in our understanding of depression as it exists within the whole person. Although neurochemical changes might maintain depression, it is not necessarily the case that neurochemical factors (or the vernacular ‘chemical imbalances’) initiate depressive processes. Indeed, these neurochemical changes are just as likely to be consequences of depressive conditions. Based on this depression re-formulation, we believe that it would be appropriate to initiate antidepressant medication treatment as an adjunctive approach if previously attempted experiential interventions, including exercise, dietary adjustments, and psychotherapy failed to achieve desired effectiveness. Further, conceptualizing neurochemical changes as depressive correlates rather than causes, lead us to agree with others who maintain that medication treatment should be considered a palliative and not curative treatment (Overholser, 2006).

[Again, please note that much of the preceding is adapted from a previously published article in the Journal of Contemporary Psychotherapy. The article was titled, “Psychotherapy and (or) Medications for Depression in Youth? An Evidence-Based Review with Recommendations for Treatment.” Citations are available in the original article.]

 

Boys and Men, Personal Reflections

Hooking Up: Two Play That Game, and Not Just on Campus

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Hey. Here’s a piece Rylee S-F wrote that articulates some of the work and thinking we’ve been doing together as a father-daughter team. The focus is on male sexuality. Give a big shout-out to Rylee for getting this in the Connecticut Review and please reblog, like, and please make the world a better place by helping promote some sensible thinking about boys/men and sex. Thanks for reading! John SF

Personal Reflections, Tough Kids Cool Counseling

The Long Road to Eagle Pass Texas

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Hi.

I’m re-posting this because today, exactly one year since I made my long trek to Eagle Pass from Montana . . . I’m back again. The drive was just as long as before, but I’m back because the folks in the Eagle Pass School District are pretty darn fun to hang out with. And so here’s the original post from last year:

 

It’s a very long way from Missoula, Montana to Eagle Pass, Texas.

Just saying.

This epiphany swept over me after the early morning Missoula to Denver flight and after the Denver to San Antonio flight and right about when, after driving from San Antonio in a rental car for about an hour, I finally saw a green mileage sign that said: Eagle Pass – 95 miles. I just laughed out loud. And even though I was all by myself, I said, “It’s a long way from Missoula to Eagle Pass.” This is just a small taste of the profound thoughts I think while traveling alone.

But time and space are relative and so I entertained myself by listening to a radio station, en Espanol. Given that I have the Spanish vocabulary of a toddler, I was quite delighted with myself when I discerned that I’d tuned in to a Christian radio station. The repeated use of the words, palabra, familia, and Dios helped me make that revelation. I also monitored the temperature via my rental car thermometer and happily observed that the outside temperature never rose above 104 degrees during my drive from San Antonio to Eagle Pass.

I like to think of myself as navigationally skilled; then again, it’s also good to remind myself that denial is more than just a river in Egypt. What I did manage to efficiently find were the Texas road construction crews. Getting to my hotel was harder. I had planned to use my internet telephone GPS, which would have been a great idea had there been internet access in Eagle Pass. This prospect began dawning on me when I passed the sign saying: Eagle Pass, pop. 26,864. At that point it was still unclear to me exactly how the Eagle Pass School District (conveniently located on the Rio Grande River) decided to have me come from Montana to do a full-day Tough Kids, Cool Counseling workshop. But, given that I’d never been to Texas before and they happened to want to pay me and then they decided to purchase 45 copies of Tough Kids, Cool Counseling, I found myself faced with an offer I couldn’t refuse.

And so, I decided to engage in a bit of disoriented driving, while studiously avoiding the bridge to Mexico. I finally found a man from India at a random hotel, who spoke English in addition to Punjab and Spanish. He was kind enough to let me use his Internet because he’d never heard of the hotel I’d booked. Then, a few wrong turns later and following an episode where my rental car transformed itself from an automatic into a manual transmission, I finally made it to the bargain Microtel hotel where they obviously take the term “micro” very seriously. Staying there required that I change into my secret Ant-man identity, thereby shrinking my expectations for Internet access, pool length, fitness facilities, and room into the size of an ant while retaining the physical strength and intellectual functioning of an adult male (I should note that I intentionally selected this hotel because it’s relatively green and was happy with my choice, despite my lightly mocking tone). The good news was that Taco-Morales was right across the street and I got to experience some authentic fajitas and red rice at prices an ant could afford.

The next day, in a coffee-free state (there are no Starbucks in Eagle Pass), I found my way to the Eagle Pass Junior High library (home of the Eagles—what a surprising team name!). That was when I discovered how they’d chosen me as their School Counseling Workshop leader. As it turns out, Montana Street is just a block or two from Eagle Pass Junior High and so they had apparently thought I lived right there ON Montana Street (and not IN the State of Montana). . . which is probably why they chose to pay me a flat rate and let me cover my own travel.

But very soon I discovered everything wonderful about Eagle Pass. I got to spend the day with Mr. Salinas, Ms. Gutierrez, Mr. Lopez, Connie, Karla, Luis, Toyoko, three women named Dora, and just enough School Counselors to scoop up 45 copies of Tough Kids, Cool Counseling. This was a group with immense compassion and dedication to making the lives of their students better. They teased me, laughed at my jokes, gently corrected my Spanish mis-pronunciations, asked for me to sign their books, and treated me with mucho mas respeto than I could ever deserve. By lunchtime they began talking about when I’d come back (I gently suggested January instead of August for my next visit). After lunch, Luis beat me at the Hand-Pushing game (I was depleted and distracted from all the energy it took to keep intermittently changing into an ant-sized person to fit into my hotel). However, one of the three Doras made an excellent volunteer for my mental set riddles (thank you Dora, for demonstrating in front of your peers that, in fact, learning can happen).

In the end, I return from Eagle Pass with renewed and sustained faith and hope in the human race. The big hearts and amazing dedication of the Eagle Pass School Counselors was inspiring. Thank-you Eagle Pass, for helping to expand my world. . . while simultaneously shrinking my expectations for hotel accommodations.

Parenting, Personal Reflections

Sweating my Way through Charlotte, North Carolina

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As my sister likes to say, “we’ve got excellent pores in our family.” By “excellent” she means to say that our pores open up and leak like the Titanic. One time, way back when I was teaching at the University of Portland, I didn’t let enough time pass between playing noon-time basketball and lecturing in an Introductory Psychology class and ended up sweating so much that my glasses fogged up.

And so you can imagine how much my pores enjoyed being in Charlotte, NC in August.

When I showed up at the Ice Cream Social on Tuesday evening I was sweating so much that I was sure everyone was thinking, “Great. It’s the night before he’s scheduled to speak and our keynote for Wednesday morning is ALREADY having a panic attack.” [It’s funny how self-consciousness about something like sweating can suddenly turn on my psychic powers, because I’m pretty sure I was able to accurately read everyone’s mind at that Ice Cream Social.] But really, it wasn’t that terrible because I only had to retreat to my room to change my shirt once during the 20 minutes I spent at the Ice Cream Social.

Note to self: When visiting high humidity regions, always pack clothing that doesn’t accentuate my excellent sweating ability of my pores.

But the real point of this blog post isn’t my personal struggle with perspiration—despite the fact that writing about my sweating is, I’m sure, intrinsically interesting as well as cathartic and desensitizing. The real point is to do some flat out bragging about the Communities In Schools of North Carolina (CIS-NC) programs.

If you don’t know about the Communities in Schools organization, you should. In North Carolina this organization includes an amazing staff with boundless positive energy that they direct toward dropout prevention. If you click on the link to their organization you’ll find a cool website with excellent information http://www.cisnc.org/. Here’s their mission statement:

The mission of Communities In Schools is to surround students with a community of support, empowering them to stay in school and achieve in life. We are part of the national Communities In Schools network, which is the leading dropout prevention organization in the country, and the only such organization that is proven to decrease the dropout rate and increase on-time graduation rates.

I have to admit that before I arrived in Charlotte, I was skeptical about their claims of being “the only organization proven to decrease the dropout rate and increase on-time graduation rates.” This skepticism came from two sources: (1) decreasing drop-out rates is just extremely difficult for everyone, and (2) I’m skeptical about everything. But, after being with the ABSOLUTELY AMAZING administration and staff of CIS-NC for only a few hours, it was clear to me how and why they’re able to help students succeed. Here are a few things I learned.

  • Not only is the staff positive, energetic, and funny, they’re also smart, savvy, and fully dedicated to improving the lives of young people.
  • They utilize a rational balance of evidence-based approaches in combination with approaches that are designed to meet the unique needs of individual schools, staff, students, and settings.
  • They operate using the “5 Basics of Communities in Schools.” These common sense AND evidence-based principles include:
  1. A one-on-one relationship with a caring adult.
  2. A safe place to learn and grow.
  3. A healthy start and a healthy future.
  4. A marketable skill to use upon graduation.
  5. A chance to give back to peers and community.

In addition to all that, I learned that their staff is sensitive, supportive, and compassionate. After all, when I delivered the keynote, they nodded and smiled (showing their listening skills), laughed at all of my jokes at exactly the right time (laughing with special vigor when I did my exorcist voice), and gave me lots of positive feedback for the rest of the morning.

Now it’s up to me to determine if they were just being especially kind to their sweaty keynote speaker or whether they really enjoyed the presentations. I’m hoping for the latter.

Parenting, Therapy with Adolescents

Hello to the Communities in Schools of North Carolina

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Tomorrow I head to Billings to fly to Charlotte, North Carolina to speak at the annual training conference for the Communities in Schools of North Carolina (CIS-NC). CIS-NC is an awesome organization that helps prevent and reduce school drop-outs. I’m honored to be a part of their annual training. You can learn more about CIS-NC at: http://www.cisnc.org/

Attached to this post is the powerpoint presentation for the Wednesday opening session.

NC CIS Warts to Wings Final REV no cartoons

And here’s the one page summary from the opening session.

From Warts to Wings Handout

And here’s the powerpoint for the break-out session on “How to Listen so Parents will Talk”

How to Listen for CIS

And the one page summary for the break-out session.

How to Listen Handout

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Strategies for Working Effectively with Challenging Clients

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Working with clients who are reluctant or resistant to counseling can be very challenging . . . unless you use skills to help minimize resistance and maximize cooperation. The following is adapted from Chapter 12: Challenging Clients and Demanding Situations of the forthcoming 5th edition of Clinical Interviewing. Remember, these skills have to come from a foundation of therapist genuineness.

Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback

Clients sometimes begin interviews with expressions of hostility, anger, or resentment. If this is handled well, these clients may eventually open up and cooperate. The key is to refrain from lecturing, scolding, or retaliating when clients express hostility. Speaking from the consultation-liaison psychiatry perspective, Knesper (2007) noted: “Chastising and blaming the difficult patient for misbehavior seems only to make matters worse” (p. 246).

Instead, empathy, emotional validation, and concession are more effective responses. We often coach graduate students on how to use concession when power struggles emerge, especially when they’re working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). For example, if a young client opens a session with, “I’m not talking and you can’t make me,” we recommend responding with complete concession of power and control: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s need for power and control and concedes an initial victory in what the client might be viewing as a struggle for power.

Empathy and Emotional Validation

Empathic, emotionally validating statements are also important. If clients express anger at meeting with you, a reflection of feeling and/or feeling validation response can let them know you hear their emotional message loud and clear. In some cases, as in the following example, therapists might go beyond empathy and emotional validation and actually join clients with a parallel emotional response:

  • “Of course you feel angry about being here.”
  • “I don’t blame you for feeling pissed about having to see me.”
  • “I hear you saying you don’t trust me, which is totally normal. After all, I’m a stranger, and you shouldn’t trust me until you get to know me.”
  • “It pretty much sucks to have a judge require you to meet with me.”
  • “I know we’re being forced to meet, but we’re not being forced to have a bad time together.”

Radical Acceptance

Radical acceptance is a dialectical behavior therapy principle and technique based on person-centered theory (Linehan, 1993). It involves consciously accepting and actively welcoming any and all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). For example, we’ve had experiences where clients begin their sessions with angry statements about the evils of psychology or counseling:

Opening Client Volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.

Radical Acceptance Return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate psychologists but they just sit here and pretend to cooperate. So I really appreciate you telling me exactly what you’re thinking.

Radical acceptance can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. Our favorite version of this is the “Love reframe” (J. Sommers-Flanagan & Barr, 2005).

Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. So let’s just get this over with.

Therapist: I hear you saying this is bullshit. You must really love your daughter . . . to come here even when you think it’s a worthless waste of your time.

Client: (Softening) Yeah. I do love my daughter.

The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone, which turns the interview toward a more pleasant focus.

Genuine Feedback

Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings . . . pausing . . . and then following with honest feedback and a solution-focused question.

“I hear you saying you hate the idea of talking with me, and I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent]. You know, you’re in legal trouble. I’d like to try to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour or we can talk about how you might dig yourself out of this legal hole you’re in. I can go either way. What do you think . . . if we had a good meeting today, what would we accomplish?”

Think about how you can incorporate, empathy, emotional validation, concession, radical acceptance, and genuine feedback into your clinical practice. For more on this, check out the 5th edition of Clinical Interviewing.

Clinical Interviewing

A General Guide to Using Stages of Change Principles in Clinical Interviewing

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This week I’ve been working on reading and editing the page proofs for the forthcoming 5th edition of Clinical Interviewing (John Wiley & Sons). The information below is from a “Putting It Into Practice” box from the 4th chapter. It focuses on a brief Q&A regarding the application of Prochaska and DiClemente’s “Stages of Change” concept in clinical interviewing and presupposes that you have basic knowledge of that particular piece of their Transtheoretical Model.

A General Guide to Using Stages of Change Principles in Clinical Interviewing

Below we pose and answer four basic questions about how to apply stages of change principles (Prochaska & DiClemente, 2005) to guide the techniques and responses you choose to use within a clinical interviewing context.

Q1: When should I use directive techniques like psychoeducation or advice?

A1: When clients are in the action or maintenance stages of change you’re free to be more directive (provided you have useful information to share that fits with what the client recognizes as his or her problem).

Q2: When should I use less directive listening responses like paraphrasing, reflection of feeling, and summarization?

A2: As a general rule, if your client is in the precontemplative or contemplative stages of change, you should primarily use nondirective listening skills to help the client look at his or her own motivations for change. This would include: (a) attending behaviors, (b) paraphrasing, (c) clarification, (d) reflection of feeling, and (e) summarizing. Many questions, especially open questions and solution-focused or therapeutic questions, may be appropriate for clients who are precontemplative or contemplative. When you’re with clients who present as precontemplative or contemplative, your best theoretical orientation choices will likely be person-centered, motivational interviewing, and/or solution-focused. Using more directive approaches can produce defensiveness or resistance with clients in precontemplative or contemplative stages.

Q3: How do I know what stage of change my client is in?

A3: We’re tempted to suggest you’ll know it when you see it . . . and there’s some truth to that. If you try directly recommending a strategy for change and the client responds defensively, you may be moving forward too fast and it’s advisable to retreat to using reflective listening skills. Conversely, if your client seems frustrated with your nondirective listening and expresses interest in changing now, then you’ve got the green light to be more directive. Also, we recommend using George Kelly’s (1955) credulous approach to assessment, meaning you can always just directly ask clients what they prefer. In our work with parents we do this explicitly by stating something like:

“I want to emphasize that this is your consultation. And so if I’m talking too much, just tell me to be quiet and listen and I will. Or, if you start feeling like you want more advice and suggestions, let me know that as well.” (J. Sommers-Flanagan & Sommers-Flanagan, 2011, p. 60)

There are also standardized methods for assessing clients’ readiness for change. Interestingly, most of these involve asking clients very direct questions about their motivation to change, how difficult they expect change to be, and how ready they are to change (all of which seem in the spirit of George Kelly’s credulous approach; for example, see (Chung et al., 2011) for a study on the predictive validity of four different measures assessing client readiness to stop smoking cigarettes).

Q4: Is the stages of change concept supported by empirical evidence?

A4: The data are mixed on whether and how much attending to and using interventions that fit your clients’ stages of change makes a difference. Of course, this is true for nearly every phenomenon in counseling and psychotherapy.  Overall, some studies show strong support for gearing your interviewing techniques to your clients’ stage of change (Johnson et al., 2008). Other studies show that stages of change focused interventions do no better than interventions that don’t tune into clients’ particular motivational stage (Salmela, Poskiparta, Kasila, Vähäsarja, & Vanhala, 2009). We recognize this isn’t the clear and decisive research outcome you might hope for, but such is the nature of our profession.

For more information on Clinical Interviewing, 5th edition, go to: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118270045.html

 

Boys and Men, Personal Reflections

What I Learned About Male Sexuality Today

4 Comments

Learning is cool. As Rylee and I work on our boys and sexual development project, we get to do lots of reading. Even better, lots of the reading is about sex.

As you may recall, last week Rylee and fell in love with Cordelia Fine’s Myths of Gender. Today, I had a different experience reading a 2007 book titled “7 Things He’ll Never Tell You {but you need to know}” written by Kevin Leman, a psychologist and “New York Times best-selling author.”

Here are a few of “Dr.” Leman’s comments and tips . . . combined with some clearly spiteful commentary from Rita and Rylee.

“The wise woman realizes that a man is wired to want things now. [Rita stops me here and says, “Wait. That’s me! I’m the one who wants things now!] And she will realize that a man who is constantly thwarted in his desires will begin to look for gratification elsewhere.” (Leman, p. 35)

Right now I’m thinking about raspberry pie. If Rita doesn’t get it for me NOW, I’ll be looking elsewhere . . . I hope she recognizes that. This is pretty good stuff. No more thwarting . . . or else! [Rylee says, “Or else you’ll get it yourself.”]

Then he says:
“. . . men . . . are not relationally centered. They identify more with things. They are visually stimulated by looking. That means whatever your guy sees is imprinted on his mind. So if he sees a sexy woman in a red dress on the subway, he may see that same woman in his thoughts again later that night, a week later, even a month later. . . . Men, on the average, have 33 sexual thoughts a day” (p. 104)

Oh my, 33 sexual thoughts a day. And how many sexual thoughts a day does a woman have. He doesn’t really address this directly, but at the end of the book he has a little quiz and one of the items goes like this: “How much does a man think about sex? . . . 33 times as much as you” (p. 177).

This is a serious math problem. And so if Rita has 5 sexual thoughts in a day, it means I’ll have 165? Now we’re talking!

On p. 106, Leman writes: “It’s been said that women need a reason for sex. Men only need a place. Men really need sex and are designed to need sex, to think about it, and to pursue it. A physically healthy married man cannot be fulfilled without it.” (p. 106) [Rylee says: Only for married men? What about all those monks? No fulfillment for them?]

Hmmm . . . sounds like sex is pretty important for guys. No fulfillment . . . period? Nothing else is fulfilling? Well, I guess if I’ve got 165 sexual thoughts in a day, maybe there’s no time to think of anything else fulfilling. Even though this isn’t really all that consistent with any other psychological theories, especially existentialism, I guess if Dr. Leman says it, it must be true.

And here’s the coup de gras . . .

“Sex is the great equalizer in a man’s life. If he meets with the accountant and is short on funds for his income tax or he got a bad job review, coming home to a willing wife makes it all better. It’s amazing what things great sex can cure for men—everything from viruses, bacterial infections, impetigo, chicken pox, the flu, and most importantly, any problem in marriage. For example if he has a fight with his wife and later that day they have sex, all of his issues are gone. They’ve resolved themselves. The problem is that for the other half of the relationship—the female—the issues aren’t resolved until they’re talked about!” (p. 107)

So sex cures the chicken pox. [Rita says: “But only for men?”] I say I wish I’d known that last summer when I had the coxsackie virus. [Rita says, “Like that was gonna happen.”] [Rylee says: “So women can cure men by sacrificing themselves to whatever disease a man has.”] [Rita says, “Women are true healers.”]

See, you learn something new every day. And sometimes it’s actually useful . . . or true.