Category Archives: Cool Counseling

The Evidence Base for Psychoanalytic Therapies: It Just Might Be Better Than You Think

Sunset 2019In recent days there’s been a bit of a kerfuffle on Twitter regarding the relative efficacy of psychoanalytic and cognitive-behavioral therapies (CBT). Of course, the standard mantra in the media and among many mental health professionals is that the science shows that CBT is superior and the treatment of choice for many, if not most, mental and emotional problems. Well, as is often the case in life and psychotherapy, reality is much less clear.

This post isn’t about fake news or alternative facts. Instead, I hope it’s about a balanced perspective. As a psychotherapist-counselor-professor-clinical psychologist, I like to think I don’t have an allegiance to any single therapy approach. Although I know I can’t claim perfect objectivity, I do have a broad view. One factor that has helped me have a broad view is that I read lots of professional journal articles in order to be able to write my theories of counseling and psychotherapy textbook.

Below, I’ve inserted an excerpt from the end of the psychoanalytic chapter of our textbook. Whether you’re a CBT or psychoanalytic fan, or perhaps a fan of a different approach, I hope you find this short review of psychoanalytic treatment efficacy interesting. The bottom line for me is captured by an old quotation from Freud (who wasn’t known for his flexible thinking). Purportedly, he said, “There are many ways and means of conducting psychotherapy. All that lead to recovery are good.” I might add the following to Freud’s comment: There are many different clients with many different problems and many different individual and cultural perspectives. I’m convinced that most clients are best served if therapists tweak their approaches to fit the client, rather than expecting the client to fit into narrow clinical procedures based on pure (or rigid) theoretical perspectives.

Here’s the excerpt . . .

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Conducting rigorous research on longer-term treatments, such as psychoanalytic therapy, is challenging and cost prohibitive. Psychoanalytic approaches are often less symptom- or diagnosis-focused, seeking instead to facilitate client insight and improve interpersonal relationships. Because empirically supported treatments focus on whether a specific psychological procedure reduces symptoms associated with a medical diagnosis, “proving” the efficacy of complex therapy approaches is difficult—especially when compared to the lesser challenges inherent in evaluating symptom-focused treatments. Partly because of these complexities, some reviewers contend that psychoanalytic psychotherapies are less efficacious than cognitive and behavioral therapies (Busch, 2015; Tolin, 2010).

The good news for psychoanalytic therapy fans is that evidence is accumulating to support treatment efficacy. The less good news is that some of the research support remains methodologically weak and the wide variety of psychoanalytic approaches makes it difficult to come to clear conclusions. Nevertheless, the most recent meta-analytic studies, literature reviews, and individual randomized controlled studies support the efficacy of psychoanalytically oriented therapies for the treatment of a variety of mental disorders. According to Leichsenring, Klein, and Salzer (2014), there is empirical support for the efficacy of psychoanalytic psychotherapies in treating:

  • Depressive disorders.
  • Anxiety disorders.
  • Somatic symptom disorders.
  • Eating disorders.
  • Substance-related disorders.
  • Borderline personality disorder.

The evidence for the efficacy of psychodynamic approaches for depressive disorders is strong. In a recent meta-analysis, Driessen and colleagues (2015) evaluated 54 studies, including 3,946 patients. They reported that short-term psychodynamic psychotherapy (STPP) was associated with improvements in general psychopathology and quality of life measures (d = 0.49–0.69) and all outcome measures (d = 0.57–1.18); they also noted that patients continued to improve at follow-up (d = 0.20–1.04). Further, no differences were found between STPP and other psychotherapies. On anxiety measures, STPP appeared significantly superior to other psychotherapies at post-treatment (d = 0.35) and follow-up (d = 0.76).

In a previous meta-analytic review, Shedler (2010) also concluded that psychodynamic therapies were equivalent to “. . . other treatments that have been actively promoted as ‘empirically supported’ and ‘evidence based’” (p. 107). He also reported that psychodynamic therapies had more robust long-term effects.

Table 2.2 provides a sampling of meta-analytic evidence supporting psychodynamic therapies. For comparison purposes, the original meta-analyses conducted by Smith and colleagues are included (Smith & Glass, 1977; Smith et al., 1980). Notably, Smith, Glass, and Miller reported that psychodynamic approaches were significantly more efficacious than no treatment and approximately equivalent to other therapy approaches.

Table 2.2 also includes the average effect size (ES or d; see Chapter 1) for antidepressant medications (ES = 0.31 for serotonin-specific reuptake inhibitors or SSRIs). This comparison data shows that psychodynamic psychotherapy is more effective than SSRI treatment for depression. Additionally, the benefits of psychoanalytic therapy tend to increase over time (Driessen et al., 2015; Shedler, 2010). This implies that psychoanalytic psychotherapy clients develop insights and acquire skills that continue to improve their functioning into the future—which is clearly not the case for antidepressant medication treatment (Whitaker, 2010). One of the ways psychotherapists explain this difference in longer term efficacy is with the statement: “A pill is not a skill.”

Table 2.2 A Sampling of Psychodynamic Psychotherapy Meta-analyses

Authors Outcome focus Number of studies ES or d
Abbass et al. (2009) General psychiatric symptoms 8 0.6
Anderson & Lambert (1995) Various 9 0.85
de Maat et al. (2009) Long-term treatment 10 0.78
Driessen et al. (2015) Depression 54 0.57–1.18
Comparison research
Turner et al. (2008) Meds for Major depression 74 0.31
Smith et al. (1977) Different therapies 375 0.68
  Many problems    
Smith et al. (1980) Different therapies 475 0.75
  Many problems    

Note: This is a sampling of meta-analytic psychoanalytic psychotherapy reviews. We’ve omitted several reviews with very high effect sizes partly because of criticisms related to their statistical methodology (see Driessen et al., 2015, and Shedler, 2010, for more complete reviews). This table is not comprehensive; it’s only a reasonable representation of psychoanalytic psychotherapy meta-analyses.

We recommend you take the preceding research findings (and Table 2.2) with a grain of salt. Conducting systematic research on something as subjective as human mental and emotional problems always includes error. One source of error is the allegiance effect (Luborsky et al., 1999). The allegiance effect is the empirically supported tendency for the researcher’s therapy preference or allegiance to significantly predict outcome study results.  Luborsky and colleagues (1999) analyzed results from 29 different adult psychotherapy studies and reported that about two thirds of the variation in outcome was accounted for by the researcher’s theoretical orientation (e.g., psychoanalytic researchers reported more positive outcomes for psychoanalytic therapy and behavior therapists discovered that behavior therapy was more effective).

The implications of the allegiance effect help explain why, shortly after Shedler’s (2010) publication extolling the virtues of psychodynamic psychotherapy, several critiques and rebuttals were published (Anestis, Anestis, & Lilienfeld, 2011; McKay, 2011). The critics claimed that Shedler’s review was biased and accused him of overlooking weaknesses within the meta-analyses he reviewed (e.g., poor outcome measures, pooling the effects of small samples with little power and poor designs, lack of treatment integrity effects). Although Shedler’s critics raised important points, the critics themselves had their own biases. The problem is that all researchers (and writers) have an allegiance of one sort of another.

One of our favorite ways of understanding the allegiance effect is articulated in a story about the great New York Yankee baseball player, Yogi Berra. One day, when a player on Yogi’s team was called out on a close play at second base, Yogi went charging on to the field to protest. The umpire explained that he, unlike Yogi, was an objective observer and that he, unlike Yogi, had been only about 5 feet from the play, while Yogi had been over 100 feet away, in the dugout. When Yogi heard the umpire’s logic, he became even angrier and snapped back, “Listen ump, I wouldn’t have seen it, if I hadn’t believed it” (adapted from Leber, 1991).

The “I saw it because I believed it” phenomenon is also called confirmation bias (Masnick & Zimmerman, 2009; Nickerson, 1998). Confirmation bias involves seeking, interpreting, and valuing evidence that supports pre-existing beliefs, while ignoring and devaluing evidence contrary to preexisting beliefs. Consequently, psychoanalytically oriented individuals see support for their perspective and behavior therapists see support for theirs. However, despite these caveats, based on accumulating research, psychodynamic approaches have a reasonably good record of efficacy.

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Although this particular review has many limitations, I’m convinced that most of us, most of the time, are better off following the advice of Marvin Goldrfried (and others) and focusing on the common therapeutic factors, or, as Norcross calls a subset of common factors, empirically-supported relationships.

For more information, check out Goldfried’s recent article on obtaining consensus in psychotherapy:  https://www.stonybrook.edu/commcms/psychology/_pdfs/clinical/Goldfried%20AP%20Consensus%20AP.pdf

 

Fear, Anxiety, Loathing, and Today’s Workshop for the Thriving Institute

Even though I’m a Montana Grizzly, being back in Bozeman is always nice. Today, Rita is insisting that we go out to Burger Bobs before my evening workshop for the Thriving Institute. To be honest, Burger Bobs sounds a little heavy for my pre-workshop meal. I’m nervous, but I guess we’ll see if that’s a mistake or not.

For those in attendance (or those not in attendance), here’s the ppts for tonight. They’re like, “amazing” or at least I hope you think so.

Thrive Anxiety Beast 2019

Anybody feeling anxious? Or like a beast?

Spidey

 

Understanding and Taming the Anxiety Beast in Your Child

Nora Twirl

I’m feeling a little nervous about going back to Bozeman this coming Thursday, November 14. This time, instead of continuing on with my latest streak of suicide and happiness presentations, the focus is on something I love even more: Parenting. I’m nervous because I obviously need help and support for coming up with titles to my talks. Somehow I’ve claimed that I’ll be taming beasts this Thursday. Looking back, I’m wondering why I made up such a grandiose sounding title. Ugh. Help wanted.

Despite my own anxiety, I’ll be presenting on behalf of Thrive, a very cool parenting education and children’s support organization in Bozeman. The event is called the Thriving Institute.

Location: Bozeman Public Library

Time: 6pm to 8pm

You can register online at: allthrive.org

Check out the fancy flyer here! Thriving Institute – Understanding and Taming the Anxiety Beast in Your Child

In anticipation of Thursday’s talk, I’m re-posting a blog from last year. It’s about children and anxiety, and it’s got an accompanying podcast. Here’s the re-post!

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Facing fear and anxiety is no easy task. It’s not easy for children; and it’s not easy for their parents. Here’s a short piece of historical fiction that captures some of the dynamics that can emerge when you’re helping children face their fears.

“I’m scared.”

My nephew turned his pleading fact toward me. He was standing on the diving board. I was a few feet below. We had waited in line together. Turning back now meant social humiliation. Although I knew enough to know that the scene wasn’t about me, I still felt social pressure mounting. If he stepped down from the diving board, I’d feel the shame right along with him. My own potential embarrassment, along with the belief that he would be better served facing his fears, led me to encourage him to follow through and jump.

“You can do it,” I said.

He started to shake. “But I can’t.”

Parenting or grand-parenting or hanging out with nieces and nephews sometimes requires immense decision-making skill. I’d been through “I’m scared” situations before, with my own children, with grandchildren, with other nephews and nieces. When do you push through the fear? When do you backtrack and risk “other people” labeling you, your son, your daughter, or a child you love as “chicken?”

This particular decision wasn’t easy. I wanted my nephew to jump. I was sure he would be okay. But I also knew a little something about emotional invalidation. Sure, we want to encourage and sometimes push our children to get outside their comfort zones and take risks. On the other hand, we also want to respect their emotions. Invalidating children’s emotions tends to produce adults who don’t trust themselves. But making the decision of when to validate and when to push isn’t easy.

I reached out. My nephew took my hand. I said, “Hey. You made it up here this time. I’ll bet you’ll make the jump next time.” We turned to walk back. A kid standing in line said, “That’s okay. I was too scared to jump my first time.”

Later, when the line had shrunk, my nephew wanted to try again. “Sure,” I said. “I’ll walk over with you.”

He made the jump the second time. We celebrated his success with high-fives and an ice-cream sandwich.

Like all words, the words, “I’m scared” have meaning and provoke reactions.

Sometimes when parents hear the words, “I’m scared” they want to push back and say something like, “That’s silly” or “Too bad” or “Buck-up honeycup” or something else that’s reactive and emotionally invalidating.

The point of the story about my nephew isn’t to brag about a particular outcome. Instead, I want to recognize that most of us share in this dilemma: How can we best help children through their fears.

Just yesterday I knelt next to my granddaughter. She was too scared to join into a group activity. She held onto my knee. We were in a public setting, so I instantly felt embarrassment creeping my way. I dealt with it by engaging in chit-chat about all the activity around us, including commentary about clothes, shoes, the color of the gym. Later, when she finally joined in on the activity, I felt relief and I felt proud. I also remembered the old lesson that I’d learned so many times before. In the moment of a child’s fear, my potential emotional pain, although present, pales in comparison to whatever the child is experiencing.

If you’d like to hear more about how to help children cope with their fears, you can listen to Dr. Sara Polanchek and me chatting about this topic on our latest Practically Perfect Parenting Podcast. Here are the links.

On iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

On Libsyn: http://practicallyperfectparenting.libsyn.com/

And follow us on Facebook: https://www.facebook.com/PracticallyPerfectParenting/

 

 

Happiness and Well-Being (in Livingston, Montana)

Cow

Yesterday, at the fabulous West Creek Ranch retreat center just North of Yellowstone Park, I introduced community leaders from Livingston, Montana to a man named James Pennebaker. It was a brief meeting. In fact, I’m not sure anyone remembers the formal introduction.

I should probably mention that James Pennebaker wasn’t in the room. The meeting consisted of me putting a short and inadequate description of one of his research studies up on a screen. The study went something like this:

Back in 1986, Pennebaker randomly assigned college students to one of two groups. The first group was instructed to write about personally traumatic life events. The second group was instructed to write about trivial topics. Both groups wrote on four consecutive days. Then, Pennebaker obtained health center records, self-reported mood ratings, physical symptoms, and physiological measures.

Pennebaker reported that, in the short-term, participants who wrote about trauma had higher blood pressure and more negative moods that the college students who wrote about trivia. But the longer term results were, IMHO, amazing. Generally, the students who wrote about trauma had fewer health center visits, better immune functioning, and overall improved physical health.

Pennebaker’s theory was that choking back important emotions takes a physical toll on the body and creates poorer health.

Since 1986, Pennebaker and others have conducted much more research on this phenomenon. The results have been similar. As a consequence, over time, Pennebaker has “penned” several books on this topic, including:

  • Opening Up: The healing power of expressing emotions
  • Writing to Heal: A guided journal for recovering from trauma & emotional upheaval
  • Expressive Writing: Words that heal
  • The Secret Life of Pronouns: What our words say about us
  • Opening Up by Writing It Down

As most of you know, after a couple decades presenting on suicide assessment and treatment, Rita and I have pivoted toward happiness and well-being. The coolest thing about talking about happiness and well-being is that doing so is WAY MORE FUN, and it results in meeting and laughing with very cool people, like the Livingston professionals.

Speaking of Livingston professionals, just in case you forgot that you met James Pennebaker, here’s a link to my powerpoints from yesterday: Livingston 2019 Final

I hope you had as much fun listening as I did talking.

Using Therapeutic Storytelling with Children: Five Easy Steps

Books

Everybody loves a good story.

Good stories grab the listener’s attention and don’t let go. I’ve been reading and telling stories for as long as I can remember. Whether its kindergartners, clients, or college students, I’ve found that stories settle people into a receptive state that looks something like a hypnotic trance.

Nowadays, mostly we see children and teens entranced with their electronic devices, television, and movies. Although it’s nice to see young people in a calm and focused state, the big problem with devices (other than their negative effects on sleep, attention span, weight, brain development, and nearly everything else having to do with living in the real world), is that we (parents, caretakers, and concerned adults), don’t have control over the electronic stories our children see and hear.

Storytelling is a natural method for teaching and learning. Children learn from stories. We’re teaching when we tell them. We might as well add our intentionally selection of stories to whatever our children might be learning from the internet.

Way back in 1997, Rita and I wrote a book called Tough Kids, Cool Counseling. One of the chapters focused on how to use therapeutic storytelling with children and teens. Although the content of Tough Kids, Cool Counseling is dated, the ideas are still solid. The following section is good material for counselors, psychotherapists, parents, and other adults who want to influence young people.

In counseling, storytelling was originally developed as a method for bypassing client resistance. Stories are gentle methods that don’t demand a response, but that stimulate, “thinking, experiencing, and ideas for problem resolution” (Lankton & Lankton, 1989, pp. 1–2)

Storytelling is an alternative communication strategy. For counselors, it should be used as a technique within the context of an overall treatment plan, rather than as a treatment approach in and of itself. For parents and caregivers, stories should be fun, and engaging . . . and told in a way to facilitate learning.

Story construction. Even if you’re an excellent natural storyteller, it can help to have a guide or structure for story construction and development. I like using a framework that Bill Cook, a Montana psychologist, wrote about and shared with me. He uses the acronym S-T-O-R-I, to organize the parts of a therapeutic story.

S: Set the stage for the story. To set the stage, you should create a scenario that focuses on a child living in a particular situation. The child can be a human or an animal or an animated object. The central child character should be described in a way that’s positive and appealing. Because much of my work back in the 1990s involved working with boys who were angry and impulsive, the following story features a boy who has an arguing problem. Depending on your circumstances, you could easily feature a girl or a child who doesn’t have a particular gender identity.

Here’s the beginning of the story.

Once upon a time there was a really smart boy. His name was Lancaster. Lancaster was not only smart, he was also a very cool dresser. He wore excellent clothes and most everyone who met Lancaster immediately was impressed with him. Lancaster lived with his mother and sister in the city.

In this example, the client’s name was Larry. If it’s not too obvious, you can give the central character a name that sounds similar to your client’s name. You may also develop a story that has other similarities to your client’s life.

T: Tell about the problem. This stage includes a problem with which the central character is struggling. It should be a problem similar to your client’s or your child’s. This stage ends with a statement about how no one knows what to do about this very difficult and perplexing problem.

Every day, Lancaster went to school. He went because he was supposed to, not because he liked school. You see, Lancaster didn’t like having people tell him what to do. He liked to be in charge. He liked to be the boss. The bad news is that his teachers at school liked to be in charge too. And when he was at home, his mother liked to be the boss. So Lancaster ended up getting into lots of arguments with his teachers and mother. His teachers were very tired of him and about to kick him out of school. To make things even worse, his mother was so mad at him for arguing all the time that she was just about to kick him out of the house. Nobody knew what to do. Lancaster was arguing with everyone and everyone was mad at Lancaster. This was a very big problem.

O: Organize a search for helpful resources. During this part of the story, the central character and family try to find help to solve the problem. This search usually results in identifying a wise old person or animal or alien creature as a special helper. The wise helper lives somewhere remote and has a kind, gentle, and mysterious quality. In this case, because Larry (the client) didn’t have many positive male role models in his life, I chose to make the wise helper a male. Obviously, you can control that part of the story to meet the child’s needs and situation.

Because the situation kept getting worse and worse and worse, almost everyone had decided that Lancaster needed help—except Lancaster. Finally, Lancaster’s principal called Lancaster’s mom and told her of a wise old man who lived in the forest. The man’s name was Cedric and, apparently, in the past, he had been helpful to many young children and their families. When Lancaster’s mother told him of Cedric, Lancaster refused to see Cedric. Lancaster laughed and sneered and said: “The principal is a Cheese-Dog. He doesn’t know the difference between his nose and a meteorite. If he thinks it’s a good idea, I’m not doing it!”

But eventually Lancaster got tired of all the arguing and he told his mom “If you buy me my favorite ice cream sundae every day for a week, I’ll go see that old Seed-Head man. Lancaster’s mom pulled out her purse and asked, “What flavor would you like today?”

After hiking 2 hours through the forest, they arrived at Cedric’s tree house late Saturday morning. They climbed the steps and knocked. A voice yelled: “Get in here now, or the waffles will get cold!” Lancaster and his mom stepped into the tree house and were immediately hit with a delicious smell. Cedric waved to them like old friends, had them sit at the kitchen table, a served them a stack of toasty-hot strawberry waffles, complete with whipped cream and fresh maple syrup. They ate and talked about mysteries of the forest. Finally, Cedric leaned back, and asked, “Now what do you two want . . . other than my strawberry waffles and this pleasant conversation?”

Lancaster suddenly felt shy. His mom, being a sensitive mom, looked up at Cedric’s big hulking face and described how Lancaster could argue with just about anyone, anytime, anywhere. She described his tendency to call people mean names and mentioned that Lancaster was in danger of being kicked out of school. Of course, Lancaster occasionally burst out with: “No way!” and “I never said that,” and even an occasional, “You’re stupider than my pet toad.”

After Lancaster’s mom stopped talking, Cedric looked at Lancaster. He grinned and chuckled. Lancaster didn’t like it when people laughed at him, so he asked, “What are YOU laughing about?” Cedric replied, “I like that line. You’re even stupider than my pet toad. You’re funny. I’m gonna try that one out. How about if we make a deal? Both you and I will say nothing but “You’re even stupider than my pet toad” in response to everything anyone says to us. It’ll be great. We’ll have the most fun this week ever. Okay. Okay. Make me a deal.” Cedric reached out his hand.

Lancaster was confused. He just automatically reached back and said, “Uh, sure.”

Cedric quickly stood up and motioned Lancaster and his mom to the door, smiling and saying, “Hey you two toad-brains, see you next Saturday!!”

Searching for helpful resources can be framed in many ways. For counselors, you might construct it to be similar to what children and parents experience during their search for a counselor. Consistent with the classic Mrs. Piggle Wiggle book series, the therapeutic helper in the story has tremendous advantages over ordinary counselors. In the Lancaster example, Cedric gets to propose a maladaptive and paradoxical strategy without risk, because the whole process is simply a thought experiment. Depending on your preference and situation, you can use whatever “treatment” strategy you like.

R: Refine the therapeutic intervention. In this storytelling model, the initial therapeutic strategy isn’t supposed to be effective. Instead, the bad strategy that Cedric proposes is designed for a core learning experience. During the fourth stage (refinement) the central character learns an important lesson and begins the behavior change process.

Both Lancaster and Cedric had a long week. They called everyone they saw a “stupid toad-brain” and said, “You’re even stupider than my pet toad” and the results were bad. Lancaster got kicked out of school. That morning, when they were on their way to Cedric’s, Lancaster got slugged in the mouth for insulting their taxi driver and he was sporting a fat lip.

When Lancaster stepped into Cedric’s tree house, he noticed that Cedric had a black eye.

“Hey, Mr. Toad-Brain, what happened to your eye?” asked Lancaster. “Probably the same thing that happened to your face, fish lips!” replied Cedric.

Lancaster and Cedric sat staring at each other in an awkward silence. Lancaster’s mom decided to just sit quietly to see what would happen. She was felt surprisingly entertained.

Cedric broke the silence. “Here’s what I think. I don’t think everyone appreciates our humor. In fact, nobody I met seemed to like the idea of having their brain compared to your pet toad’s brain. They never even laughed once. Everybody got mad at me. Is that what things are usually like for you?”

Lancaster muttered back, “Uh, well, yeah.” But this week was worse. My best friend said he doesn’t want to be best friends and my principal got so mad at me that he put my head in the toilet of the boys’ bathroom and flushed it.”

Cedric rolled his eyes and laughed, “And I thought I had a bad week. Well, Lanny, mind if I call you Lanny?”

“Yeah, whatever, Just don’t call me anything that has to do with toads.”

“Well Lanny, the way I see it, we have three choices. First, we can keep on with the arguing and insulting. Maybe if we argue even harder and used different insults, people will back down and let us have things our way. Second, we can work on being really nice to everyone most of the time, so they’ll forgive us more quickly when we argue with them in our usual mean and nasty way. And third, we can learn to argue more politely, so we don’t get everyone upset by calling them things like ‘toad brains’ and stuff like that.”

After talking their options over with each other and with Lancaster’s mom, Cedric and Lancaster decided to try the third option: arguing more politely. In fact, they practiced with each other for an hour or so and then agreed to meet again the next week to check on how their new strategy worked. Their practice included inventing complimentary names for each other like “Sweetums” or “Tulip” and surprising people with positive responses like, “You’re right!” or “Yes boss, I’m on it!”

As seen in the narrative, Lanny and Cedric learn lessons together. The fact that they learn them together is improbable in real life. However, the storytelling modality allows counselor and client the opportunity to truly form a partnership and enact Aaron Beck’s concept of collaborative empiricism.

I: Integrating the lesson. In the final stage of this storytelling model, the central character articulates the lesson(s) learned.

Months later, Lancaster got an invitation from Cedric for an ice cream party. When Lancaster arrived, he realized the party was just for him and Cedric. Cedric held up his glass of chocolate milk and offered a toast. He said, “To my friend Lanny. I could tell when I first met you that you were very smart. Now, I know that you’re not only smart, but you are indeed wise. Now, you’re able to argue politely and you only choose to argue when you really feel strongly about something. You’re also as creative in calling people nice names as you were at calling them nasty names. And you’re back in school and, as far as I understand, your life is going great. Thanks for teaching me a great lesson.”

As Lanny raised his glass for the toast, he noticed how strong and good he felt. He had learned when to argue and when not to argue. But even more importantly, he had learned how to say nice things to people and how to argue without making everyone mad at him. The funny thing was, Lanny felt happier. Mostly, all those mad feelings that had been inside him weren’t there anymore.

At the end of this story (or whatever story you decide to use), you can choose to directly discuss the “moral of the story” or not. In many cases, leaving the story’s message unstated is useful. Or you might ask the child, “What do you think of this story?”

Letting the child consider the message provides an opportunity for intellectual stimulation and may aid in moral development. Although it would be nice to claim that therapeutic storytelling causes immediate behavior change, the more important outcome is that storytelling provides a way for an adult and a child to have pleasant interactions around a story . . . with the possibility that, over time, positive behavior change may occur.

Why You Should Open with a Focus on the Negative When Using a Strength-Based Suicide Treatment Model

Keno Horse

I’m working on a book manuscript tentatively titled something like: Strength-Based Suicide Assessment and Treatment. As I do more work and professional training in this area, I’m struck by the natural dialectic involved in the whole area of suicide (I’m sure Marsha Linehan discovered this long ago).

One dialectic on my mind today involves the fact that although I’m calling the approach that I’m writing about “Strength-Based,” I often (but not always) advise clinicians to open their sessions with a focus on negative distress. The following excerpt takes a bit of content from my 7.5 hour (3-part) published video with Psychotherapy.net and explains my rationale for opening a session with a focus on negative or painful emotions. You can access the 3-part training video here: https://www.psychotherapy.net/video/suicidal-clients-series

Here’s the case example:

In the following excerpt, I’m working with Kennedy, a 15-year-old girl whose parents referred her to me for suicide ideation (see https://www.psychotherapy.net/video/suicidal-clients-series, Sommers-Flanagan, 2018). Although I might meet with her parents first, or with the whole family, in this case I chose to start therapy with her as an individual. My opening exchange with Kennedy is important because, in contrast to what you might expect from a “strength-based” approach, my focus with her is distinctly negative. Pay close attention to the italicized words and [bracketed explanation].

John:  Kennedy, thank you for meeting with me. Let me just tell you what I know, okay, because I know that you’re not exactly excited to be here. But the thing is that I know that your parents have said you’ve been talking about suicide off and on for a little while, and so they wanted me to talk with you. [I already know that suicide ideation is an issue with Kennedy, so I share that immediately. If I pretend that I don’t already know about her and her situation, it will adversely affect our rapport. This is a basic principle for working with teens, but also true for adults: Lead with a statement of what you know . . . and be clear about what you don’t know.]

And I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so I guess if you’re even willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is that you’re feeling? [You’ll notice that my opening question has a negative focus. The reason I’m starting with a question that focuses on Kennedy’s negative affect and pulls for what makes her feel bad or sad or miserable is because (a) I want to start with Kennedy’s emotional distress, because that’s what brings her to therapy, and (b) I want to immediately begin linking her emotional distress to situations or experiences that trigger her distress. By doing this, I’m focusing on the presumptive primary treatment goal (according to Shneidman) for all clients who are suicidal, and that is to reduce the perceived intolerable or excruciating emotional distress. In Kennedy’s case, one of my very first treatment targets is to reduce the frequency and intensity of whatever it is that’s triggering Kennedy’s suicide ideation. We’ll get to the positive, strength-based stuff later.]

Kennedy: I think I’m just like really busy every day. I am in volleyball, and I got a lot of homework, and I don’t get a lot of sleep. So, it’s really stressful getting up early, and my parents are always fighting, and sometimes I miss the bus, and they don’t want to drive me. So, I have to call one of my older friends to drive me, and sometimes I’m late, and I just – it’s stressful, and the teachers get mad, but it’s not my fault.

John:   Yeah. So, you’ve got some stress piling up, volleyball, school, sometimes being late, and your parents arguing. Of those, which one adds the most misery into your life? [Again, my focus is purposefully on the negative. I want to know what adds the most misery to Kennedy’s life so that I can work with her and her family or her and her school to decrease the stimulus or trigger for her misery.]

Kennedy: I think being at home is the hardest. In volleyball at least I find some joy. Like I like enjoy being on the court and playing with my team. They’re there to lift me up. But like my parents, I don’t like being at home.

John:  Okay. What do you hate about it? [When Kennedy says, “I don’t like being at home” she’s not providing me with specific information about the trigger for her distress, so I continue with that focus and stay with the negative and use a word (hate) that I think is a good match for how a teenage girl might sometimes feel about being with her family.]

Kennedy: I just – they’re always fighting. Sometimes my dad will leave, and my mom cries, and I’ll cry. And he’s just mean, and she’s mean, and they’re both mean to each other. And I just lock myself in my room.

John:   Yeah. So, even as I listen to you talk, it feels like this is a – just being around them – I don’t know what the feeling is, maybe of just being alone. Like they’re fighting, and you retreat to your room. Any other feelings coming up when that happens? [Although I’m trying to tune into specific feeling words to link to what’s happening for Kennedy, I’m also being tentative and vague and wanting to collaboratively explore the right words to use with Kennedy.]

Kennedy: I don’t know. Just sometimes I don’t feel like – I don’t feel like I have a home, or my family is not there for me, and sometimes I just don’t feel like living anymore. [Kennedy uses the term “feel like” which often is a signal that she’s talking about a cognition and not an emotion. For example, “I don’t feel like I have a home” is likely more of a cognition that leaves her with an emotion like sadness. But it’s too soon to be that emotionally nuanced with Kennedy and the important part of what she’s saying is that there’s a pattern that’s something like this: her parents’ fighting triggers a cognition, that triggers an unspecified emotion, and that triggers the cognition of “I just don’t feel like living anymore.”]

John:   Yeah. So, there are times when the family stuff feels so bad, that’s when you start to think about suicide?

Kennedy: Yeah.

Using Shneidman’s (1980) model to guide my initial interactions with Kennedy leads me to focus on her immediate emotional distress and the triggers for her distress. Exploring her distress and the triggers takes me to an early treatment plan (that will likely be revised and refined).

  1. I will focus on Kennedy’s immediate distress and collaboratively work with her on a plan to reduce her distress and create more positive affect.
  2. I will focus on specific situational variables that trigger Kennedy’s suicide ideation. Part of the treatment plan is likely to involve her parents and to try to get them to stop their intense “fighting” in her presence.
  3. As I aim toward distress reduction and reducing or eliminating the distress trigger, I will keep in mind that—like most teenagers—it may be very difficult for me to get Kennedy to agree to let me work directly with her parents on their fighting. Getting Kennedy on board for an intervention with her parents will test my therapeutic and relational skills.

While I’m working on this next book, I’ll be posting excerpts like this. As always, I would love your feedback and input on this content. Please post comments here, or email me directly at: john.sf@mso.umt.edu.

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