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Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Recommendations for Developing and Using a Positive Working Alliance

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Although Freud started the conversation, he might not recognize contemporary models of the working alliance. This is because Freud advocated analyst emotional distance and a detached psychoanalytic stance, whereas today’s working alliance involves therapists initiating a process of collaborative engagement with clients.

Therapists who want to develop a positive working alliance (and that should include all therapists) will integrate strategies for doing so during initial interviews and beyond. Based on Bordin’s (1979) model, alliance-building strategies would focus on (a) collaborative goal setting; (b) engaging clients on mutual therapy-related tasks; and (c) development of a positive emotional bond. Additionally, feedback monitoring within clinical interviews is recommended.

Initial interviews and early sessions appear especially important to developing a working alliance. Many clients who enter your office will be naïve about what will be happening in their work with you. This makes including role inductions or explanations of how you work with clients essential. Here’s an example from a cognitive-behavioral perspective:

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

Asking direct questions about what clients want from counseling and then listening to them and integrating that information into your treatment plan is also important: In cognitive therapy this is often referred to as making a problem list (J. Beck, 2011).

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

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

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

Client:         Sounds good to me.

Engaging in a collaborative goal-setting process—and not proceeding with therapy tasks until it’s clear that mutual goals (even temporary mutual goals) have been established

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

Client:         Absolutely yes. If we can climb those three mountains it will be great.

Soliciting feedback from clients during the initial session and ongoing in an effort to monitor the quality and direction of the working alliance. Although there are a number of instruments you can use for this, you can also just ask directly:

We’ve been talking for 20 minutes now and so I just want to check in with you on how you’re feeling about talking with my today. How are you doing with this process?

Making sure you’re able to respond to client anger or hostility without becoming defensive or launching a counterattack is essential to establishing and maintaining a positive working relationship. In our work with challenging young adults, we apply Linehan’s (1993) “radical acceptance” concept. For example, an initial session with an 18-year-old male started like this:

Therapist:    I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:         You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).

Therapist:    Thanks for telling me about that. I definitely want to avoid getting punched in the nose. And so if I accidentally say anything that offends you I hope you’ll tell me, and I’ll try my best to stop.

In this case the therapist accepted the client’s aggressive message and tried to transform it into a working concept in the session.

Having specific therapy tasks (no matter your theoretical orientation) that fit well with the mutually identified therapy goals. For example, if illuminating unconscious processes is a mutually identified goal, then using free association can be a task that makes sense to the client. On the other hand, if you’ve agreed to work toward greater self-acceptance and greater acceptance of frustrating people in the client’s life, then engaging in intermittent mindfulness tasks will feel like a reasonable approach.

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Why Therapists Should Never Say, “I know how you feel”

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The following excerpt is adapted from the fifth edition of the text, Clinical Interviewing (John Wiley & Sons, 6th edition forthcoming in October).

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

Many writers have tried operationalizing Carl Rogers’s core conditions. However, efforts to transform person-centered therapy core conditions into specific behavioral skills always seem to fall short. As Natalie Rogers (J. Sommers-Flanagan, 2007) emphasized, trying to translate the core conditions into concrete behaviors is usually a sign that the writer or therapist simply doesn’t understand person-centered principles.

This lack of understanding occurs principally because core Rogerian attitudes are attitudes, not behaviors. This is a basic conceptual principle that has proven difficult to understand—perhaps especially for behaviorists. The point Rogers was making then (in the 1950s), and that still holds today, is that therapists should enter the consulting room with (a) deep belief in the potential of the client; (b) sincere desire to be open, honest, and authentic; (c) palpable respect for the individual self of the client; and (d) a gentle focus on the client’s inner thoughts, feelings, and perceptions. Further complicating this process is the fact that the therapist must rely primarily on indirectly communicating these attitudes because efforts to directly communicate trust, congruence, unconditional positive regard, and empathic understanding is nearly always contradictory to each of the attitudes.

A counselor educator friend of ours, Kurt Kraus, articulated why trying to directly communicate understanding is problematic. He wrote:

When a supervisee errantly says, “I know how you feel” in response to a client’s disclosure, I twitch and contort. I believe that one of the great gifts of multicultural awareness is for me accepting the limitations to the felt-experience of empathy. I can only imagine how another feels, and sometimes the reach of my experience is so short as to only approximate what another feels. This is a good thing to learn. I’ll upright myself in my chair and say, “I used to think that I knew how others felt too. May I teach you a lesson that has served me well?” (J. Sommers-Flanagan & Sommers-Flanagan, 2012) (p. 146)

Kraus’s lesson is an excellent one for all of us. The phrases, “I know how you feel” and “I understand” should be stricken from the vocabulary of counselors and psychotherapists.

Clinical Interviewing

The DSM-5 as Poetry

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This morning I was trying to make fun of the DSM-5. My strategy was to read passages from the DSM-5 Introduction to Rita after breakfast. Somehow, I must have read them slowly and poetically because Rita really liked the passages . . . which I didn’t expect.

Rita’s response inspired me to place the DSM passages into an appropriate poetry format. And so although I’ve taken the liberty to title and format the words based on my own judgments, the words themselves are taken directly from the DSM-5 (with page numbers cited, so you can find them yourselves).

 Diagnosing Peter Piper

The symptoms in our diagnostic criteria

are part

of

the relatively limited repertoire

of

human emotional responses to

internal

and

external stresses

that are generally maintained in a

homeostatic balance

without a disruption in normal functioning.

It requires clinical training to recognize

when the combination

of

predisposing,

precipitating,

perpetuating,

and

protective

factors

has resulted in a

psychopathological

condition in which

physical signs and symptoms exceed

normal

ranges. [From the DSM-5, p. 19]

 

Shifting Boundaries and Thresholds

The boundaries between normality and pathology

vary

across cultures

for specific types

of behaviors.

Thresholds of tolerance

for specific symptoms

or behaviors

differ

across cultures,

social settings,

and families.

Hence,

the level at which an experience becomes problematic

or pathological

will differ. (DSM-5, p. 14)

 

Counseling and Psychotherapy Theory and Practice, Parenting

Practicing Cultural Humility with Parents

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Alfred Adler (1958) claimed that every child is born into a new and different family. He believed that with every additional member, family dynamics automatically shift and therefore a new family is born (J. Sommers-Flanagan & Sommers-Flanagan, 2004a). If we extend Adler’s thinking into the cultural domain, it might be appropriate to conclude: “Every family is born into a new and different culture.”

[This is an excerpt from “How to Listen so Parents will Talk and Talk so Parents will Listen.” It’s at: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_5?ie=UTF8&qid=1369460232&sr=1-5%5D

To be sure, culture is not a static condition; it’s a malleable and powerfully influential force in the lives of parents and children. Vargas (2004) stated,

“Culture is not about outcome. Culture is an ever-changing process.  One cannot get a firm grip of it just as one cannot get a good grasp of water.  As an educator, what I try to do is to teach about the process of culture—how we will never obtain enough cultural content, how important it is to understand the cultural context in which we are working, and how crucial it is to understand our role in the interactions with the people with whom we want to work or the communities in which we seek to intervene. . . .  I do not want to enter the intervention arena (whether in family therapy or in implementing a community-based intervention) as an “expert” who has the answers and knows what needs to be done.  I am not a conquistador, intent on supplanting my culture on others.  I have a certain expertise that, when connected with the knowledge and experience of my clients, can be helpful and meaningful to my clients.” (p. 429)

In part, Vargas was making the point that it’s more important for professionals to practice cultural humility than it is to view ourselves as culturally competent.

A Cultural Dialectic

All professionals should strive to be culturally sensitive and humble, seeking to respect and prize human diversity for the richness, variety, and surprises it brings to life.  But while embracing culture, it’s important to acknowledge that there’s no perfect culture, and sometimes cultural practices need to change or evolve for the sake of a given child, parent, or family.  Therefore, although we value divergent cultural perspectives, it’s also reasonable  to question whether specific cultural beliefs and rituals are useful or healthy to individuals, families, and communities. This is a cultural dialectic—similar to the radical acceptance dialectic discussed in Chapter 1.

When working with parents, it’s the professional’s job to do the cultural accepting and the parents’ job to do the cultural questioning. You should accept the parents’ cultural background, heritage, and parenting practices. However, if in the process of examining cultural influences on parenting, parents take the lead in questioning their culturally influenced parenting practices, you can and should remain open to helping parents push against cultural forces to make positive changes. For example, parents may want to discuss any of the following topics with you:

  • Whether or not to have their infant son circumcised
  • Their daughter’s body-image issues as they relate to American cultural values toward thinness
  • Whether it’s acceptable for their Muslim daughter to attend school or pursue higher education
  • Traditional Native American values and their children’s potential tobacco use

Helping parents determine whether their own cultural values clash with individual and/or family well-being is a delicate and potentially explosive process.  The challenge is to remain relatively neutral while helping parents evaluate cultural practices using their own parent-child-family health and well-being standards.

Case: Tobacco, Culture, and Addiction

Parent: I’m worried about my son and whether he’s started smoking. I use tobacco, in traditional Indian ceremonies, but I usually end up smoking more than I want to, and I see it as a bad habit, too. I’m not sure how to approach this with him because I don’t want to be a hypocrite.

Consultant: Tell me some ideas you’ve had, from your cultural perspective, about how to get the message you want to get to your son.

Parent: I want him to know that tobacco use should beceremonial or sacred, even though I use it more often than that. I know regular smoking is very unhealthy and so I don’t want him to have it as a habit, but I don’t know how to tell him that.

Consultant: If you think about someone from your tribe whom you really respect, how do you think that person would handle it?

Parent: In my tribe it’s really important to respect your elders. I’m my son’s mother and he should respect me, but you know how that goes. Maybe if I asked someone else, someone older and with even more respect than me, maybe that would help.

Consultant: Whom would you pick to help you talk with your son about this?

Parent: My older brother, his uncle, is pretty high up in the Tribal Government and maybe I could ask him to tell my son it would be better not to smoke, even though lots of Indian people smoke.

Consultant: Do you think your brother would be willing to give your son that message?

Parent: Yes. He’s traditional in some ways, but he’s very much against all smoking and drinking.

Consultant: You and your brother are both right about the dangers of regular tobacco use. As I imagine this discussion, I can see the two of you having a big impact on your son. But I guess there’s also the issue of your smoking and your son’s knowledge of that. Can you have your brother talk about that with your son, too? Or maybe both of you should do this together. How do you think this might work best?

In this case example, for the most part, the consultant is remaining neutral and respectful of the parent’s cultural traditions and yet, at the same time, helping her explore how to get her son a strong and clear message about not smoking tobacco.

Following the Parents’ Lead in Cultural Identity and Cultural Understanding

For most of us, culture is so deeply woven into our lives that it travels below awareness. From time to time we may glimpse it and wonder how it came to be that we choose to engage in specific cultural behaviors, such as:

  • Sitting on the couch with our children watching The Simpsons
  • Getting eggs from the store rather than directly from backyard chickens
  • Going to church on Palm Sunday where a processional, complete with a donkey, waits quietly in the sanctuary
  • Deferring to one’s husband
  • Expecting our oldest son to take care of us
  • Gathering with friends to overeat and watch the Super Bowl
  • Wearing a yarmulke, burkha, or other garments or pieces of cloth to cover our bodies or heads

Culture carries with it many questions, answers, and mysteries. As you can see from the preceding list, culture is ubiquitous; it’s impossible to escape its influence. It’s also impossible to accurately judge someone else’s cultural identity on the basis of physical appearance or initial impressions (Hays, 2008).

When working with parents, you shouldn’t assume parents’ cultural attitudes and experiences in advance. This is true no matter how similar or dissimilar to you the parents appear.  It’s best to begin with a clearly stated attitude of openness and then follow the parents’ lead.

Consultant: So, you grew up in Malawi?

Parent: Yes. I came to the United States when I was twenty-four.

Consultant: I don’t know how much of your Malawi tradition influences your parenting and so I hope it will be okay with you if, on occasion, I ask you about that.

Parent:  That’s no problem at all.

Consultant: And, as we talk, I hope you’ll feel free to tell me about anything that comes up or seems important about your particular cultural approach to parenting.

Parent: Yes. I’m comfortable with that.

Whether the parent is Laotian, Belizean, Argentine, French Canadian, or from any other cultural tradition, you should remain open to his or her particular and potentially diverse parenting approaches. However, you should also be open to helping parents question whether their own approaches to parenting are bringing them the results they desire. This is your professional duty. Again, the basic principle is to follow the parents’ lead in questioning cultural parenting practices and not become a cultural conquistador who tells all parents the one right way to be a parent.

Clinical Interviewing

The Exciting New Preface from Clinical Interviewing (5th edition)

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It’s hard to adequately express the excitement surrounding the upcoming publication of the DSM-5. Oops. I meant to write: “the 5th edition of Clinical Interviewing.” I knew there was a 5 in there somewhere.

To help the many world citizens eagerly anticipating this 5th edition, I’m including, hot off of my computer, the first part of the preface. I know . . . it really couldn’t get much more exciting than this.

Who knows, soon I might even be releasing the second part of the preface to this long-awaited masterpiece. [I hope you all can recognize the sarcasm I’m directing toward myself when you read this. It’s just that I’m working on the preface right now and I felt the need to post something on my blog . . . and these two things suddenly merged in space and time.]

Here it is.

Preface

Clinical interviewing is the cornerstone for virtually all mental health work. It involves integrating varying degrees of psychological or psychiatric assessment and treatment. The origins of clinical interviewing long precede the first edition of this text (published in 1993).

The term interview dates back to the 1500s, originally referring to a face-to-face meeting or formal conference. The term clinical originated around 1780; it was used to describe a dispassionate, supposedly objective bedside manner in the treatment of hospital patients. Although difficult to determine precisely when clinical and interview were joined in modern use, it appears that Jean Piaget used a variant of the term clinical interview in 1920 to describe his approach to exploring the nature and richness of children’s thinking. Piaget referred to his procedure as a semi-clinical interview (see Sommers-Flanagan, Zeleke, & Hood, in press).

Our initial exposure to clinical interviewing was in the early 1980s in a graduate course at the University of Montana. Our professor was highly observant and intuitive. We would huddle together around an old cassette player and listen to fresh new recordings of graduate students interviewing perfect strangers. Typically, after listening to about two sentences our professor would hit the pause button and prompt us: “Tell me about this person.”

We didn’t know anything, but would offer limited descriptions like “She sounds perky” or “He says he’s from West Virginia.” He would then regale us with predictions. “Listen to her voice,” he would say, “she’s had rough times.” “She’s depressed, she’s been traumatized, and she’s come to Montana to escape.”

The eerie thing about this process was that our professor was often correct in what seemed like wild predictions. These sessions taught us to respect the role of astute observations, experience, and intuition in clinical interviewing.

Good intuition is grounded on theoretical and practical knowledge, close observation, clinical experience, and scientific mindedness. Bad intuition involves personalized conclusions that typically end up being a disservice to clients. Upon reflection, perhaps one reason we ended up writing and revising this book is to provide a foundation for intuition. In fact, it’s interesting that we rarely mention intuition in this text. Although one of us likes to make wild predictions of the future (including predictions of the weather on a particular day in Missoula, Montana, about three months in advance), we still recognize our limitations and encourage you to learn the science of clinical interviewing before you start practicing the art.

Language Choices

We live in a postmodern world in which language is frequently used to construct and frame arguments. The words we choose to express ourselves cannot help but influence the message. Because language can be used to manipulate (as in advertising and politics), we want to take this opportunity to explain a few of our language choices so you can have insight into our biases and perspectives.

Patients or Clients or Visitor

Clinical interviewing is a cross-disciplinary phenomenon. While revising this text we sought feedback from physicians, psychologists, social workers, and professional counselors. Not surprisingly, physicians and psychologists suggested we stick with the term patient, whereas social workers and counselors expressed strong preferences for client. As a third option, in the Mandarin Chinese translation of the second edition of this text, the term used was visitor.

After briefly grappling with this dilemma, we decided to primarily use the word client in this text, except for cases in which patient is used in previously quoted material. Just as Carl Rogers drifted in his terminology from patient to client to person, we find ourselves moving away from some parts and pieces of the medical model. This doesn’t mean we don’t respect the medical model, but that we’re intentionally choosing to use more inclusive language that emphasizes wellness. We unanimously voted against using visitor—although thinking about the challenges of translating this text to Mandarin made us smile.

Sex and Gender

Consistent with Alfred Adler, Betty Freidan, contemporary feminist theorists, and American Psychological Association (APA) style, we like to think of ourselves as promoting an egalitarian world. As a consequence, we’ve dealt with gender in one of two ways: (1) when appropriate, we use the plural clients and their when referring to case examples; and (2) when necessary, we alternate our use between she and he.

Interviewer, Psychotherapist, Counselor or Therapist

While working at a psychiatric hospital in 1980, John once noticed that if you break down the word therapist it could be transformed into the-rapist. Shocked by his linguistic discovery, he pointed it out to the hospital social worker, who quipped back, “That’s why I always call myself a counselor!”

This is a confusing issue and difficult choice. For the preceding four editions of this text we used the word interviewer because it fit so perfectly with the text’s title, Clinical Interviewing. However, we’ve started getting negative feedback about the term. One reviewer noted that he “hated it.” Others complained “It’s too formal” and “It’s just a weird term to use in a text that’s really about counseling and psychotherapy.”

Given the preceding story, you might think that we’d choose the term counselor, but instead we’ve decided that exclusively choosing counselor or psychotherapist might inadvertently align us with one professional discipline over another. The conclusion: Mostly we use therapist and occasionally we leave in the term interviewer and also allow ourselves the freedom to occasionally use counselor, psychotherapist, and clinician.

Parenting

Building a Therapeutic Relationship with Parents: Part III – Collaboration

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Collaboration, as an attitude, requires that at least to some extent, parenting professionals come from a position of “not knowing” (Anderson, 1993; Anderson & Goolishian, 1992). As Anderson (1993) stated: “The not knowing position is empathic and is most often characterized by questions that come from an honest continuous therapeutic posture of not understanding too quickly” (p. 331).

[This excerpt is from How to Listen so Parents will Talk . . . http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_5?ie=UTF8&qid=1368845509&sr=1-5%5D

Not knowing requires professionals to resist the ubiquitous impulse to be all-knowing experts. Resisting the impulse to demonstrate one’s expertise is especially important when initially meeting with and working with parents.

It can be very difficult for parenting professionals to  establish and maintain a collaborative attitude. This is partly because human services providers who work with parents also need to be experts and must demonstrate their expertise. Similar to radical acceptance, collaboration between professionals and parents is a dialectic where the professional embraces both the parents’ expertness and his or her own expertise.

Some writers have emphasized that true collaboration between professionals and parents requires a form of leaderlessness (Brown, Pryzwansky, & Schulte, 2006; Kampwirth, 2006). In contrast, our position is that professionals who work with parents can and should bring the following knowledge, skills, and expertise to the consulting office:

  • How to lead or direct a counseling or consultation meeting
  • How to quickly form collaborative relationships and a working alliance with parents
  • Knowledge of what contemporary research says about child development and child psychopathology
  • A wide range of theoretically diverse and research-informed strategies and interventions to use with parents
  • A wide range of theoretically diverse and research-informed strategies and techniques for parents to implement with their children

At the same time, parents are also experts who bring the following knowledge and expertise into your office:

  • Their own personal memories and experiences of being parented
  • Knowledge and experience of their children’s unique temperament and behavior patterns
  • Awareness of their personal parenting style and efforts to parent more competently
  • Knowledge of their existing parenting strategies as well as the history of many other parenting ideas they have tried and found to be more or less helpful
  • An understanding of their limits and abilities to use new or different parenting strategies and techniques

In a very practical sense, it would be inappropriate (and probably ineffective) to ignore the fact that parents come to human services professionals expecting advice and guidance about how to be and become better parents. This is the frame from which virtually all parenting interventions flow. Consequently, if the consultant or therapist behaves too much like an equal and doesn’t act at all like an expert who offers concrete and straightforward advice, the meeting will likely fail because the basic assumption that the therapist is a helpful expert will be violated.

On the other hand, for many reasons, parents are in a vulnerable state and consequently, if they feel their parenting consultant  is acting like a judgmental or condescending expert, they will usually become defensive and antagonistic. To counter this possibility, the professional  needs to hold a collaborative attitude that honors the parents’ knowledge and experience. This collaborative attitude will help parents see themselves as respected and relatively equal partners in the therapeutic and/or educational consultation process.

Overall, the model we describe in this book (How to Listen so Parents will Talk and Talk so Parents will Listen) emphasizes that, from a position of respect, interest, and curiosity, parenting consultants, counselors, and therapists work to quickly establish a partnership with parents. When therapeutic or educational work with parents is most successful, parents will likely perceive you as an empathic, accepting, and collaborative expert willing to offer a wide range of theoretically divergent, practical, meaningful, and simple suggestions for how to parent more effectively.

 

Personal Reflections

This is Why I Have a Blog (in 212 words)

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While visiting my parents recently an older gentleman on a scooter rode up and greeted me. We had a friendly conversation within the confines of my parents’ gated community. He said his dog had mistaken me for his son. I looked down and saw a small dog or large rodent sniffing my shoes. Then his son emerged from the house. The son was quite animated as he was taking a smoke break from his online gaming.

The next morning I saw the son again. He was pedaling his bicycle slowly, smoking, and looking rather like a homeless man. He didn’t seem to recognize me.

I found myself thinking I felt reassured that the older gentleman’s very small dog obviously had a very small brain.

But who am I to say whom or what I do or do not resemble. Maybe I’m more like a gaming and smoking homeless man on the street than I think. After all, I can’t see myself very well anyway.

This is the nature of my internal conversations. A swing towards the too critical and too judgmental followed by a swing back toward self-critique.

This might be why B.F. Skinner suggested that thinking is irrelevant.

This also might be why I have a blog and not a dog.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Therapy with Adolescents

Your Life is Now: Trapper Creek Reflections

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The Road

Note: This is a re-post. I had a chance to drive to Trapper this past week with one of our doc students and I was reminded of the powerful life experiences that happen at Trapper Creek Job Corps.

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

Sometimes on Thursday or Fridays I drive from Missoula to Trapper Creek Job Corps. Then I drive back the same day. It’s a 140 mile round trip. Sometimes I have interns with me. The company makes the miles go by more quickly. Sometimes the interns are very nervous sitting next to me for the whole drive and consequently compete to see who gets the back seat. This makes me wonder if maybe I shouldn’t quiz them about theories of counseling and psychotherapy as we drive there together. Although I wonder about this . . . I haven’t changed my behavior. Maybe this means I’m trying to scare them all into the back seat.

This week I was on my own. When this is the case I usually begin wondering why the heck I drive all these miles. Of course, I get paid to go to Trapper Creek. That’s one answer I give to myself. But I keep wondering anyway. It’s a long day, usually 11 or 12 hours. And when I’m about halfway there, 45 minutes into dodging deer with 45 more minutes to deal with Bitterroot drivers, I begin planning my retirement from Trapper Creek.

This is my 10th year (2013). I know the road and I know the deer and I know the Bitterroot drivers, who, in an apparent show of independence, nearly always drive either 10 mph under or 10 mph over the speed limit.

Today my retirement planning ended shortly after arriving at Trapper Creek. There were three straight appointments scheduled for me: three straight chances to do something more than talk about how to do psychological assessment and psychotherapy. And then a chance to observe and give feedback to the nursing staff and a chance to offer my unsolicited opinion to the physician on how to deal with an ingrown toenail and then a fourth student to see and a staff consultation and a meeting and a quick hello to our three University of Montana school counseling interns and wild typing of reports and poof . . . the day is over without a moment to ponder life or reflect on retirement.

The drive back to Missoula is nearly always better. There are stories to tell, opportunities to second guess myself, and unrealistic hopes and fantasies about having possibly helped someone. The miles melt away.

[The following stories are vague and distorted to preserve anonymity]

Today, with no interns for company my buddy John Cougar Mellencamp joined me on the drive back. We decided to sing together. We sang the same song so many times we lost count.

Your Life is Now

This is your time . . . to do what you will do

The first two young women were graduating from Trapper and moving on to advanced Job Corps training. They needed brief clinical interviews and mental status exams. These two hard working and delightful young women are at Trapper because they’ve experienced poverty and want to improve their lives.

Your life is now

One had a history of having been diagnosed with two severe mental disorders. Before coming to Trapper she’d been on two very powerful psychotropic medications. Funny thing: At Trapper she attained a very high level of functioning without medications . . . for nine straight months!

Your life is now

She had many “citations” for positive behavior. The staff love her. There was no shred of evidence that she had a mental disorder. So I just told her so. She grinned, looked at me, and said, “I guess that’s pretty good news.” Yep, pretty good news.

Your life is now

The second young woman was equally impressive.

In this undiscovered moment

But my last appointment, a young man with a history of trauma, really made my day.

We had visited two weeks previously and had made a plan to try some EMDR for his troubling trauma symptoms. He was eager and right on time. We talked briefly to warm up. He chose a memory. We went through various rating procedures included in the EMDR protocol.

Lift your head up above the crowd

We did several sets of eye movements. I did my usual wandering in and out of the “proper” EMDR protocol. After 10 minutes, we stopped and I asked him to reflect on his experience. He turned his head back and forth and said, “My neck doesn’t hurt anymore.”

We could shake this world

Then he smiled and said, “I feel like I can breathe again.” And then, “I wish I’d known about this ten years ago.”

If you would only show us how

Thank you Trapper Creek

Thank you fine young women and men

Thank you nurses and doctor and interns and staff

Thank you deer and Bitterroot drivers

Thank you for showing me how to shake this world and make a difference.

 Your life is now

Counseling and Psychotherapy Theory and Practice, Parenting

Building a Therapeutic Relationship with Parents: Part II – Using Radical Acceptance

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Building a Therapeutic Relationship with Parents: Part II – Using Radical Acceptance

Radical acceptance is a central therapeutic attitude held by practitioners who work effectively with parents. Radical acceptance is both an attitude and a clinical technique. This concept was originally articulated by Marsha Linehan (1993) and is a foundational component of dialectical behavior therapy. It involves a particular attitude that builds on Carl Rogers’s core therapeutic condition of unconditional positive regard as well as Eastern (Buddhist) philosophy.

Radical acceptance enables helping professionals to approach each client or parent with an overarching, pervasive dialectic belief, which we translate as, “I completely accept you just as you are and I am committed to helping you change for the better.” When working with parents, consultants strive to simultaneously hold both of these beliefs or attitudes. On the surface, these attitudes may seem contradictory, thus the term dialectic. At a deeper level, in a helping relationship, each attitude is necessary to complete the other.

As a technique, radical acceptance serves two main functions. First, it can help you refrain from expressing negative personal reactions to statements by parents that inadvertently push your buttons (we’ll focus more on button-pushing in Chapter 2). If you hear a statement that pushes an emotional button for you, having a radical acceptance attitude would help remind you that your job is to fully accept the person in the room with you—as is. In this situation, you don’t have to say anything as you simply quiet your roiling reactions. You can just be present and nonreactive.

Second, beyond momentary silence, radical acceptance allows parenting professionals to actively embrace whatever attitudes or beliefs parents bring into the consulting room. As we’ve stated previously (J. Sommers-Flanagan & Sommers-Flanagan, 2007):

The generic version or statement of radical acceptance is to graciously welcome even the most absurd or offensive . . . [parent] . . . statements with a response like, “I’m very glad you brought that [topic] up.” (p. 275)

Radical acceptance is especially warranted when parents say something you find disagreeable. This may include racist, sexist, or insensitive comments. For example:

Parent: I believe in limiting my children’s exposure to gay people. Parents need to keep children away from evil influences.

Consultant: Thanks for sharing your perspective with me. I’m glad you brought up your worries about this. Some parents have similar beliefs but won’t say them in here. So I especially appreciate you being honest with me about your beliefs. [Adapted from Sommers-Flanagan & Sommers-Flanagan, 2007, p. 276.]

Rest assured, radical acceptance does not mean agreeing with the content of whatever parents say. Instead, it means moving beyond feeling threatened, angry, or judgmental about parents’ comments and authentically welcoming whatever comes up during the session. The main purpose of welcoming disagreeable or challenging parent comments is to communicate your commitment to openness. If you don’t communicate and value openness by welcoming all remarks, parents or caregivers may never admit their core underlying beliefs. And if parents cover up their true beliefs—especially disagreeable or embarrassing beliefs—there will be no opportunity for insight or change because the underlying beliefs will never be exposed to the light of personal and professional inspection.

Similar to person-centered therapy, one key to using radical acceptance effectively is genuineness or congruence. This means you should never falsely welcome parents’ racist, sexist, insensitive, or outrageous comments. Instead, you should welcome such comments only if you really believe that hearing them is a good thing that can benefit the counseling or consultation process.

Radical acceptance also involves letting go of the immediate need to teach parents a new and better way. We must confess that we haven’t always maintained an attitude of radical acceptance ourselves. During one memorable session, upon hearing the classic line, “I got spanked and I turned out just fine!” John, being in an impatient and surly mood, barely managed to suppress an extremely destructive impulse (he wanted to say, “Are you really so sure you turned out fine?”). Nevertheless, a judgmental and dismissive comment still slipped out and he said: “I can’t tell you how many times I’ve heard parents say what you just said.” Not surprisingly, that particular session didn’t proceed with the spirit of empathy, acceptance, and collaboration we generally recommend.

This leads us to some obvious advice: Although you cannot be radically accepting all the time, you should always avoid radical judgment. There’s no need to test the “How about I treat parents in a judgmental, dismissive manner?” technique. Outcomes associated with judgmental and disrespectful counselor behavior are quite undesirable.

Stay Tuned for Part III on Building a Therapeutic Relationship with Parents tomorrow.

Counseling and Psychotherapy Theory and Practice, Parenting

Building a Therapeutic Relationship with Parents: Part I

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Every parent is unique. But as a group, most parents have similar interests and goals. What this means for consultants and counselors and psychotherapists is that parents constitutea unique population and therefore to work effectively with parents requires a specifically tailored treatment approach and training in how to provide educational and therapeutic services for parents.

The following is an adapted excerpt from the book, “How to Listen so Parents will Talk and Talk so Parents will listen. For more info, go to: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_4?ie=UTF8&qid=1366501670&sr=1-4

To work effectively with parents, consultants or practitioners should use an approach that, similar to person-centered therapy, is characterized by three core attitudes: (1) empathic understanding; (2) radical acceptance; and (3) collaboration.

Empathy for Parents and Parenting

As is well-known, empathic understanding is one of the three core conditions for psychotherapy originally identified by Carl Rogers (1942; 1961; 1980). Over the years, research has left no doubt that therapist empathy facilitates positive therapy outcomes (Goldfried, 2007; Greenberg, Watson, Elliot, & Bohart, 2001; Mullis & Edwards, 2001). As applied to parents, empathy involves:

The therapist’s ability and willingness to understand the parent’s thoughts, feelings, and struggles from the parent’s point of view and an ability to see, more or less completely, through the parent’s eyes and adopt the parent’s frame of reference . . . . It means entering the private perceptual world of a parent. (adapted from Rogers, 1980, pp. 85, 142)

When working with parents, counselors, psychologists, and other human services professionals must learn to sensitively enter into the parent’s unique perceptual world. The practitioner needs to demonstrate empathy and sensitivity for specific parenting challenges. A person-centered perspective also implies that professionals who work with parents show empathy for the barrage of criticism, scrutiny, and associated insecurity that parents experience due to their exposure to social and media sources. Brazelton and Sparrow (2006) capture one way in which socially driven parental insecurity can manifest itself:

When Mrs. McCormick held Tim in her lap at the playground, she sat alone on a bench across from the other mothers as if she were ashamed of Tim’s clinging. She knew that if she sat by other mothers, they would all give her advice: “Just put him down and let him cry—he’ll get over it.” “MY little girl was just like that before she finally got used to other kids.” “Get him a play date. He can learn about other children that way.” (p. 8)

This example illustrates how parents anticipate criticism and work hard to avoid it. If you’ve been a parent or you work with parents, you know how easy it is for them to feel defensive about their children’s behaviors and their parenting choices. This is partly because, like Mrs. McCormick, they’re unable to measure up to narrowly defined parenting standards and cannot face the cascade of criticism or advice they’re likely to receive when their child doesn’t behave perfectly in social settings. To provide an optimally empathic environment, practitioners should have and show empathy or attunement with parents’ sensitivity to perceived or actual criticism and counter this sensitivity by amplifying their support and acceptance (we’ll cover therapeutic methods for amplifying support and acceptance in greater detail in Chapter 4).

Similar to the empathic attitude associated with person-centered therapy, it’s crucial for professionals who work with parents to hold the attitude that parenting is naturally difficult and that making mistakes or having a child who publicly misbehaves is nothing to feel shameful about. By maintaining this attitude, practitioners provide a nonjudgmental and empathic space for parents to explore their personal doubts and fears. This is the way the theory works: By being nonjudgmental, compassionate, and openly supportive, parenting professionals provide an environment free from societal conditions of worth, which then stimulates parents to become more open and collaborative when examining their weaknesses with a trusted professional.

Part II of this three part blog post continues tomorrow.