Category Archives: Clinical Interviewing

The Montana Suicide Assessment and Treatment Planning Model is Coming to a Location Near You

While hanging out on Twitter, I noticed that E. David Klonsky, a fancy suicide researcher from the University of British Columbia tweeted about a brand new article published in the Journal of Affective Disorders.

The article, titled, “Rethinking suicides as mental accidents” makes a case for what the authors (Drs Ajdacic-Grossab, Hepp, Seifritz, and Bopp from Switzerland) refer to as the starting point for a “Rethink.”

Aside from their very cool use of the term rethink—a term I’m planning to adopt and overuse in the future—the authors’ particular “rethink” has to do with reformulating completed suicides as mental accidents, instead of mental illness. They concluded, “The mental accident paradigm provides an interdisciplinary starting point in suicidology that offers new perspectives in research, prediction and prevention” (p. 141).

For those of you who follow this blog and know me a bit, it will come as no surprise that I commend the authors for moving away from the term mental illness, but that I also think they should move even further away from even the scent of pathologizing suicidal thoughts and behaviors.

All this brings me to an important announcement.

Starting on the evening of May 16 and continuing onto May 17, in partnership with the Big Sky Youth Empowerment Project (thanks Pete and Katie), I’ll begin the launch of some public and professional suicide trainings in Montana. These trainings will include evening public lectures (starting May 16 in Bozeman) and professional trainings on suicide assessment and treatment planning (starting May 17 in Bozeman).

Going back to the “rethink” of suicide as a mental accident, I want to emphasize that my goal with these lectures and workshops is to reshape discussions about suicide from illness-focused to health and wellness focused. Rethink of it as a strength-based approach to suicide assessment and treatment planning. And you can also rethink of it as no accident.

For more information on the public lecture, check out this flyer: BYEPSAWpublic (1)

For more information on the professional suicide assessment and treatment planning workshop, check out this link: https://go.byep.org/advances and flyer: BYEPSAWclinical (1)

And if you can’t make these events, no worries, as I mentioned, this is a launch . . . which means there’s more coming later this year . . . in Billings, in Great Falls, and in Missoula.

Finally, if you want a workshop like this in your city, let me know. The good people of Big Sky Youth Empowerment are committed to delivering a more positive message about suicide assessment and treatment planning to other locations around the state; maybe we can partner up and do some important work together.

Thanks for reading and happy Sunday evening!

data or data

Upcoming Webinars (without Spiderman)

Spiderman II

As a Marvel Comics fan since 1963, I’ve always felt uncomfortable doing webinars without mentioning Spiderman. Now that I’m on record for my Spiderman-influenced childhood, I feel my comfort-level returning to normal.

Somehow, in the next month or so, I’ve gotten myself involved in a plethora of webinars, as long as you define “plethora” as five.

Although it’s sticky business, the purpose of this blog post is to gently promote said webinars. You might be interested. I think they’re mostly free, or accessible through a particular professional association (e.g., WSASP).

Here’s the line-up (starting tomorrow!), along with webinar titles and links.

  1. Wednesday, March 13 – 2pm EDT (12pm MDT):

Transforming Therapeutic Relationships into Evidence-Based Practice: Practical Skills for Challenging Therapy Situations

Sponsored by TherapySites. To register, go to:    https://register.gotowebinar.com/register/2888908924358696194?source=Association

Many counselors and psychotherapists deeply believe in the therapeutic power of relationships, but feel mandated to practice using empirically-supported technical procedures. In this presentation, John will illustrate how relational approaches to counseling are also specific treatment methods.

Specifically, in this webinar, Dr. Sommers-Flanagan will be discussing:

– 9 different evidence-based relationship factors with practical examples of how to use these factors in challenging situations

– Using self-disclosure effectively and how to respond to difficult questions

– Recognizing relational ruptures and make repairs

– How to respond to clients who are not cooperating with the counseling process

– What to say when clients have suicidal thoughts and feel hopeless

All participants will have access to a handout describing and illustrating how to use evidence-based relationship factors to enhance counseling and psychotherapy practice.

  1. Friday, March 15, 2019, from 1pm-4pm PDT (12pm to 3pm MDT):

Tough Kids, Cool Counseling: Part I, Assessment and Engagement

Sponsored by the Washington State Association of School Psychologists (WSASP). To participate, you’ll need to be a WSASP member. https://www.wsasp.org/event-3158525?CalendarViewType=1&SelectedDate=3/12/2019

Counseling adolescent students can be immensely frustrating or splendidly gratifying. To address this challenge, participants in this workshop will refine their skills for managing resistance and implementing specific brief counseling techniques. Using video clips, live demonstrations, and other learning activities, the workshop presents four essential principles and 10 assessment and engagement strategies for influencing “tough students.” Group discussion, breakout skill-building, and other learning activities will be integrated.

  1. Thursday, April 4, 2019, from 12pm to 1pm (somewhere, TBA).

Adlerian Psychology and Cognitive-Behavioral Therapy

Sponsored by Adler University. To participate, go to: https://www.adler.edu/page/community-engagement/center-for-adlerian-practice-and-scholarship/calendar/upcoming-events

Most Adlerian theorists view Individual Psychology as the foundation for modern cognitive-behavior therapy. But most modern cognitive-behavior therapists rarely credit Adler or know much about his theory. In this webinar, John Sommers-Flanagan, author of Counseling and Psychotherapy Theories in Context and Practice (Wiley, 2018) will present two short case vignettes, while engaging in a lively debate with himself over the similarities and distinctions of Adlerian therapy and CBT.

  1. Thursday, April 18, 2019 – 1pm EDT (11am MDT): “Breathing New Life into Your Dead, White Counseling and Psychotherapy Theories Course”

Sponsored by WileyPlus. To register, go to:  https://www.wileyplus.com/wiley-webinar-series/

Teaching traditional counseling and psychotherapy theories courses can feel dull and boring. In this webinar session, John Sommers-Flanagan will share pedagogical strategies for integrating culture into theory, and engaging students with here-now activities that bring the dusty old theories to life. This webinar will include specific recommendations for how to integrate culture and feminist ideas into traditional theories. Learning activities will be demonstrated, including: (a) early intercultural memories; (b) sex, feminism, and psychoanalytic defense mechanisms; (c) empowered narrative storytelling; and (d) spiritual and behavioral forms of relaxation. Handouts for each activity will be available on https://johnsommersflanagan.com/.

  1. Friday, April 19, 2019, from 1pm-4pm PDT (12pm to 3pm MDT):

Tough Kids, Cool Counseling: Part II, Specific Counseling Techniques and Strategies

Sponsored by the Washington State Association of School Psychologists (WSASP). To participate, you’ll need to be a WSASP member. https://www.wsasp.org/event-3158525?CalendarViewType=1&SelectedDate=3/12/2019

In this advanced workshop, participants will learn 10 (or more) specific counseling techniques designed to promote positive change in middle and high school students. Using video clips, live demonstrations, and role-playing practice, participants will refine their skills for implementing change strategies with students. Techniques include problem solving, empowered storytelling, cognitive storytelling, cognitive–behavioral therapy for anger management, the three-step emotional change trick, early interpretations, and the fool-in-the-ring. Diversity-sensitive approaches will be highlighted.

In closing, I randomly selected the words of Spiderman (from 1966, #36, p. 20). “You’ll have to make it a solo the rest of the way down, Lootie! This is where I get off!”

Wow! I never realized Spiderman was a quotation machine or that he used so many exclamation points!

Have a great week!

John

 

 

Suicide Assessment and Treatment Planning: Resources for Professionals

The Road

As you probably know, suicide rates are and have been on the rise. Here’s what the Centers for Disease Control said several months ago: “From 1999 through 2017, the age-adjusted suicide rate increased 33% from 10.5 to 14.0 per 100,000” (CDC, November, 2018).

Although the CDC’s report of a 33% increase in the national suicide rate is discouraging, the raw numbers are even worse. In 1999, an estimated 29,180 Americans died by suicide. As a comparison, in 2017 (the latest year for which data are available), there were 47,173 suicide deaths. This represents a 61.9% rise in the raw number of suicide deaths over the past 17 years.

Along with rising suicide rates, there’s also a palpable rise in anxiety and panic among mental health and healthcare professionals, teachers, and the public. Even though suicides still occur at a low rate (14 per 100,000), it’s beginning to feel like a public health crisis. We don’t have much evidence that current intervention and prevention efforts are working, and the continued tragic outcomes (about 129 suicide deaths each day in the U.S.) are painful and frustrating.

The purpose of this post is simply to offer resources. I’ve been working in this area for many years; my sense is that having additional resources to help professionals feel more competent can reduce anxiety and probably increases competence. Here are some resources that might be helpful.

  1. In 2018 I published an article in the Journal of Health Service Psychology. The purpose of the article was to provide clear ideas about how psychological providers can be more effective in how they work with clients or patients who are suicidal. You can click here to access a pdf of the article. Conversations About Suicide by JSF 2018
  2. I’ve been working with some of my doctoral students on alternatives to the traditional (and failed) approach of using client risk factors to categorize or estimate suicide risk. One product of this work is an evidence-based list of eight potential suicide dimensions. These suicide dimensions can be used with other models (e.g., safety planning) to guide collaborative treatment planning. To see a description of the eight dimensions and a treatment planning form based on the eight dimensions, you can click on the following links. Suicide TPlanning Handout            Suicide TPlanning Handout Blank
  3. Barbara Stanley and Gregory Brown developed the “Safety Planning Intervention.” For information about their intervention and access to their safety planning form, you can go to their website: http://suicidesafetyplan.com/Home_Page.html
  4. Along with Victor Yalom and some other contributors, this past year I helped produce a 7.5 hour professional training video titled, Assessment and Intervention with Suicidal Clients. You can buy this 3-part video series through Psychotherapy.net and can access a preview of the video series here: http://www.psychotherapy.net/video/suicidal-clients-series
  5. I’m a big fan of David Jobes’s work on the collaborative assessment and management of suicide. You can check out his book on Amazon: https://www.amazon.com/Managing-Suicidal-Risk-Second-Collaborative/dp/146252690X/ref=sr_1_1?crid=29DN6ZM2BUCV3&keywords=david+jobes+suicide&qid=1551837394&s=gateway&sprefix=david+jobes%2Caps%2C177&sr=8-1
  6. Later this spring and this fall, in collaboration with the Big Sky Youth Empowerment Program and the University of Montana, I’ll be offering several low-cost six-hour training workshops in four different Montana locations. These trainings will include research data collection, as well as an opportunity to participate in follow up booster trainings—booster sessions that will happen about three months after you attend an initial six-hour session. If you’re interested in participating in these Montana Suicide Assessment and Treatment Planning Workshops, you can email me, send me your email via a comment on this blog, or begin following this blog so you don’t miss out when I share the dates, times, and locations, and registration information in an upcoming post.

I hope this information is helpful to you in your work with clients struggling with suicide. Together, hopefully we can make a difference.

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

Stone Smirk

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

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

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

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

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

Termination Checklist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The End of Mental Illness, Part I

Irrigation Sunrise

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mental Illness Lacks a Suitable Professional Definition

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

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

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

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

Mental Illness is Too Judgmental

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

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

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

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

Mental Illness Resists De-stigmatization

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

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

 

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

Here’s a photo of me talking too much.

OLYMPUS DIGITAL CAMERA

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Guidelines for Using Congruence in Counseling and Psychotherapy

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

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

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

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

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

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

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

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

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

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

Case Example 7.1:

Congruence Across Cultures

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

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

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

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