Category Archives: Cool Counseling

A Sneak Peek at Our Upcoming Suicide Assessment and Treatment Book with the American Counseling Association

Spring Sunrise and Hay

Rita and I are spending chunks of our social distancing time writing. In particular, we’ve signed a contract to write a professional book with American Counseling Association Publications on suicide assessment and treatment planning. We’ll be weaving a wellness and strength-oriented focus into strategies for assessing and treating suicidality.

Today, I’m working on Chapter 6, titled: The Cognitive Dimension. We open the chapter with a nice Aaron Beck quotation, and then discuss key cognitive issues to address with clients who are suicidal. These issues include: (a) hopelessness, (b) problem-solving impairments, (c) maladaptive thinking, and (d) negative core beliefs.

Then we shift to specific interventions that can be used to address the preceding cognitive issues. In the following excerpt, we focus on collaborative problem solving and illustrate the collaborative problem-solving process using a case example. As always, feel free to offer feedback on this draft content.

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Collaborative Problem-Solving

Though not a suicide-specific intervention, problem-solving therapy is an evidence-based approach to counseling and psychotherapy (Nezu, Nezu, & D’Zurilla, 2013). Components of problem-solving are useful for assessing and intervening with clients who are suicidal. As Reinecke (2006) noted, “From a problem-solving perspective, suicide reflects a breakdown in adaptive, rational problem solving. The suicidal individual is not able to generate, evaluate, and implement effective solutions and anticipates that his or her attempts will prove fruitless” (p. 240).

Extended Case Example: Sophia – Problem-Solving

In Chapter 5 we emphasized that clinicians should initially focus on and show empathy for clients’ excruciating distress and suicidal thoughts. However, there often comes a moment when a pivot toward the positive can occur. Questions that help with this pivot include:

  • What helps, even a tiny bit?
  • When you’ve felt bad in the past, what helped the most?
  • How have you been able to cope with your suicidal thoughts?

In response to these questions, clients who are suicidal often display symptoms of hopelessness, mental constriction, problems with information processing, or selective memory retrieval. Statements like, “I’ve tried everything,” “Nothing helps,” and “I can’t remember ever feeling good,” represent cognitive impairments. Even though your clients may think they’ve tried everything, the truth is that no one could possibly try everything. Similarly, although it’s possible that “nothing” your client does helps very much, it’s doubtful that all their efforts to feel better have been equally ineffective. These statements indicate black-white or polarized thinking, as well as hopelessness and memory impairments (Beck et al., 1979; Reinecke, 2006; Sommers-Flanagan & Sommers-Flanagan, 2018).

Pivoting to the Positive

Picking up from where we left off in Chapter 5, after exploring the distress linked to Sophia’s suicide ideation in the emotional dimension, the counselor (John) pivots to asking about the positive (“What helps?”) and then proceeds into a problem-solving assessment and intervention strategy. One clearly identified trigger for Sophia’s suicidal thinking is her parent’s fighting. She cannot directly do anything about their fights, but she can potentially do other things to shield herself from the downward cognitive and emotional spiral that parental fighting activates in her.

John: Let’s say your parents are fighting and you’re feeling suicidal. You’re in your room by yourself. What could you do that’s helpful in that moment? [The intent is to shift Sophia into active problem-solving.]

Sophia: I have a cat. His name is Douglas. Sometimes he makes me feel better. He’s diabetic, so I don’t think he’ll live much longer, but he’s comforting right now.

John: Nice. My memory’s not perfect, so is it okay with you if I write a list of all the things that help a little bit? Douglas helps you be in a better mood. What else is helpful?

Sophia: I like music. Blasting music makes me feel better. And I play the guitar, so sometimes that helps. And volleyball is a comfort, but I can’t play volleyball in my room.

John: Yeah. Great. Let me jot those down: music, guitar, volleyball, and being with your cat. And volleyball, but not in your room! I guess you can think about volleyball, right? And how about friends? Do you have friends who are positive supports in your life?

Although the fact that Douglas the cat has diabetes includes a depressive tone, the good news is that Sophia immediately engages in problem-solving. She’s able to identify Douglas and other things that help her feel better.

Throughout problem-solving, regularly repeating positive coping strategies back to the client is important. In this case, John summarizes Sophia’s positive ideas, and then asks about friends and social support—a very important dimension in overall suicide safety planning.

Sophia: Yeah, but we’re all busy. My friend Liz and I hang out quite a bit. I can walk into her house, and it will feel like my house. But we’re both in volleyball, so we’re both really busy. But our season will end soon. Hopefully that will help.

John: Ok, the list of things that seem to help, especially when you’re in a hard place with your parents fighting: Douglas the cat, music, guitar, and volleyball, and friends. Anything else to add?

Sophia:  I don’t think so.

Often, the next step in collaborative problem-solving is to ask clients for permission to add to the list, thus turning the process into a shared brain-storming session. At no time during the brainstorming should you criticize any client-generated alternatives, even if they’re dangerous or destructive. In contrast, clients will sometimes criticize your ideas. When clients criticize, just agree with a statement like, “Yeah, you’re probably right, but we’re just brainstorming. We can rank and rate these as good or bad ideas later.”

Overall, the goal is to use brainstorming to assess for and intervene with mental constriction. During brainstorming, Sophia and John generated 13 things Sophia could do to make herself feel better. Sophia’s ability to brainstorm in session is a positive indicator of her responsiveness to treatment.

 

The Three-Step Emotional Change Technique

chicken-head950

Newsflash: I’m asking for a favor. UMOnline (of the University of Montana) is partnering with Rita and me to produce the free Happy Habits for Hard Times video series. Yesterday’s episode was “The Three-Step Emotional Change Technique” (described below). In appreciation for their technical and motivational support, I want to push some traffic to UMOnline. Here’s their link to the video: https://www.youtube.com/watch?v=Ji_q-T_SwZE and here’s a link to the series:  https://coehs.umt.edu/happy_habits_series_2020/default.php. Please click, like, subscribe, and share. Our main goal is to help people cope effectively during these immensely difficult times.

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When I first started doing counseling and psychotherapy, I planned to do health psychology or behavioral medicine with people suffering from medical problems. I envisioned working with patients with high blood pressure, asthma, pain, and other physical ailments—all of which can be treated through psychological methods.

But life has a funny way of delivering a karate chop to our best laid plans. Instead of medical referrals, a parade of young people arrived in my office in blisteringly bad moods. They told me I was ugly, that I should fuck-off, and that there was no way in hell they would ever talk to me; sometimes they even threatened to destroy my office or physically attack me.

I also got one referral for a guy in his mid-50s who wanted to work on his high blood pressure. Turns out, the blood pressure treatment process was numbingly boring. To my surprise, I much preferred being pelted with insults by the nasty kids.

Early in the process I realized, these weren’t nasty kids, but instead, these were kids in nasty moods because of their difficult life circumstances. None of their insults or anger or sadness were about me, and so I modified Harold Mosak’s (1985) pushbutton technique, turning it into a simple, three-step emotional change technique to help my young clients deal with their bad moods. Using my creative naming skills, I called it the “Three-step emotional change trick.” I ended up liking the technique so well that I did it in my office, with myself, with parents, during professional workshops, and with classrooms full of 4th and 5th graders. Mostly it worked. Sometimes it didn’t. Here’s how it goes.

Introduction

Before teaching the three steps, I introduced the idea that bad moods were normal and offered a taste of emotional education. I asked, “Have you ever been in a bad mood?” Obviously, all the kids nodded, flipped me off, or said things like, “No duh.” My response was something like, “Yeah, me too.”

Then I’d ask, “Have you ever had somebody come up to you and tell you to cheer up?” All the kids said, “Yes!” and then followed up with how stupid they thought it was when someone told them to cheer up. I would agree and commiserate with them on how ridiculous it was for anyone to ever think that saying “Cheer up” would do anything but piss the person off even more.

At some point, I’d say, “I’ll never tell you to cheer up. Don’t worry about that. If you’re in a bad mood, I figure you’ve got a good reason to be in a bad mood, and so I’ll just respect your mood and let it be.”

Then I’d swoop in with my sales pitch. “But hey. Have you ever been in a bad mood and get stuck there and have it last longer than you wanted it to?”

Nearly always there was a head nod; I’d join in and admit to the same. “Damn those bad moods. Sometimes they last and last and hang around way longer than they need to.”

“If it’s okay with you,” I’d say, “I’d like to teach you this thing I call the three-step emotional change trick. It’s a way for you to change your mood, but only when you want to change your mood, and not when somebody tells you to cheer up. This trick is a way for you to be the captain of your own emotional ship.”

Maybe my memory is warped, but I can’t remember any young person ever refusing to let me teach them the three-steps. I think most people find their moods challenging, and so if you’re selling a technique or trick to give them more control, pretty much everyone wants to learn it. That’s why I’m sharing it with you now.

Step one is to feel the feeling. Feelings come around for a reason. Hardly ever do they come out of nowhere. We need to notice them, feel them, and contemplate their meaning. The big questions here are: How can you honor and feel your feelings? What can you do to respect your own feelings and listen to the underlying message? Over the years, I’ve heard many answers. Here are a few. But you can generate your own list.

  • Frowning or crying if you feel sad
  • Grimacing and making various angry faces into a mirror if you feel angry
  • Drawing an angry, ugly picture
  • Punching or kicking a large pillow (no real violence though)
  • Going outside and yelling (or screaming into a pillow)
  • Scribbling on a note pad with a black marker
  • Writing a nasty note to someone (but not delivering it)
  • Using your words, and talking to someone about what you’re feeling

Step two is to think a new thought or do something different. This step is all about intentionally doing or thinking something that might change or improve you mood. The big question here is: What can you think or do that will put you in a better mood?

I discovered that kids and adults have amazing mood-changing strategies. Here’s a sampling:

  • Tell a funny story (for example, yesterday in math, my friend Todd farted)
  • Tell a joke (What do you call it when 100 rabbits standing in a row all take one step backwards? A receding hareline).
  • Tell a better joke (Why did the ant crawl up the elephant’s leg for the second time? It got pissed off the first time.)
  • Get some exercise
  • Smile into a mirror
  • Watch funny internet cat videos
  • Talk to someone you trust
  • Put a cat (or a chicken or a duck) on your head
  • Chew a big wad of gum

I’m sure you get the idea. Nobody knows better than you what might put you in a good mood . . . so, when you’re ready, you should use your own self-knowledge to move into a better mood.

Step three is to spread the good mood. Spreading the good mood is based on the fact that moods are contagious. In fact, although COVID-19 is very contagious, moods might be even more contagious. I’d say things like this to my young clients:

“I want to tell you another interesting thing about moods. They’re contagious. Do you know what contagious means? It means you can catch them from being around other people who are in bad moods or good moods. Like when you got here. I noticed your mom was in a bad mood too. It made me wonder, did you catch the bad mood from her or did she catch it from you? Anyway, now you seem to be in a much better mood. And so I was wondering, do you think you can make your mom “catch” your good mood?”

How do you share good moods? Keep in mind that saying “Cheer up” is off-limits. Here’s a short list of what I’ve heard from kids and adults.

  • Do someone a favor
  • Smile
  • Hold the door for a stranger
  • Offer a random act of kindness
  • Offer a real or virtual hug
  • Listen to someone who wants or needs to talk
  • Tell someone, “I love you” (you can even do this while social distancing)

Step four might be the best and most important step in the three-step emotional change trick. With kids, when I move on to step four, they always interrupt:

“Wait. You said there were only three steps!”

“Yes. That’s true. That’s what I said. What’s interesting about the three-step emotional change trick is that it has four steps. It has for steps because emotions are complicated and surprising. And so there are four steps. This last step is for you to teach someone else the three steps.”

The other surprising thing about the three-step emotional change trick is that nobody ever complains that it has four steps. For whatever reason, the complexity of emotions seems to overshadow the need to count accurately. In fact, as you read this, you may have discovered an additional step. I wouldn’t be surprised if it turned out that the three-step emotional change trick actually has five steps. If you’ve got a fifth step, please share!

 

Free Video Links for Online Teaching

JSF Travel

This past week I’ve been grateful for the many professionals and organizations (including my publisher, John Wiley & Sons) who are providing free guidance and materials to help with the transition from face-to-face teaching to online instruction. In an effort to contribute back in a small way, I’m posting 10 counseling- and psychotherapy-related videos that can be integrated into online teaching. These videos are free and posted on my YouTube channel. The links are all below with a brief description of the video content.

Some of these videos are rough cuts and all of them are far from perfect demonstrations; that’s partly the point. Although many of the videos show reasonably good counseling skills and interesting assessment processes and therapeutic interventions, none of the videos are scripted, and so there’s plenty of room for review, analysis, critique, and discussion. You can show them as efforts to do CBT, SFBT, Motivational Interviewing, administration of a mental status examination, etc., and prompt students to describe how they would do these sessions even better.

These videos are meant to stimulate learning. In an ideal world, I would include a list of discussion questions, but I’ll leave that to you. If you like, please feel free to use these videos for educational purposes. Here’s the annotated list with video links:

  1. Counseling demonstrations with a 12-year-old.
    1. Opening a counseling session: https://www.youtube.com/watch?v=rHHrMC8t6vY
    2. The three-step emotional change trick: https://www.youtube.com/watch?v=ITWhMYANC5c
    3. John SF demonstrates the What’s Good About You? informal assessment technique: https://www.youtube.com/watch?v=MUhmLQUg_g8
    4. Closing a session: https://www.youtube.com/watch?v=GpuH80tf2jM
  2. Demo of assessment for anger management with a solution-focused spin with a 20-year-old client: https://www.youtube.com/watch?v=noE2wMMNLY4
  3. Demo of motivational interviewing with a 30-year-old client: https://www.youtube.com/watch?v=rtN7kEk0Sv4
  4. Demo of the affect bridge technique with an 18-year-old: https://www.youtube.com/watch?v=fEtiGuc914E
  5. Demo of CBT for social anxiety with a graduate student: https://www.youtube.com/watch?v=jfVeeGJHFjA
  6. Demo of an MSE with a 20-year-old: https://www.youtube.com/watch?v=adwOxj1o7po
  7. A lecture vignette of a demonstration of psychoanalytic ego defense mechanisms: https://studio.youtube.com/video/E818UlgHMXY/edit
  8. The University of Montana Department of Counseling does a spoof video of The Office: https://www.youtube.com/watch?v=eM8-I8_1CqQ

Good luck with the transition to online teaching and stay healthy!

John S-F

Happiness Homework: Conduct Two Natural Talent Interviews

Strengths

Back in the 1950s, at the University of California, a guy named Joseph met a guy named Harrington. They were both psychologists and both interested in self-awareness and interpersonal relationships. Together, combining their knowledge and experiences, they came up with a simple way to integrate their ideas about self-awareness and social awareness. Being cool and creative types (I’m guessing about this, because I never met them), to name their concept they fused or integrated their two first names.

You may have studied the Johari Window in Introductory Psychology. Just in case you didn’t, or just in case you’ve forgotten whatever you learned about it, here are a few facts.

  1. The Johari window is pronounced the Joe-Harry Window. . . because Joe Luft and Harry Ingham named it after themselves.
  2. The Johari window is designed as a tool for helping people (like us!) to expand our self-awareness.
  3. The Johari Window has four quadrants or “rooms” (see the Figure below) 

    The Open Area. The top-left room represents the part of the self that that’s wide open. It includes parts of you that are known to you (self-awareness) and those same parts that are known to others.

    The Hidden Area. The bottom left room is the part of ourselves that we know, but that we hide from others. People who are transparent generally have a small private or “hidden area.”  People who consider themselves “private people” probably have bigger hidden areas.

    The Blind Spot. The top right area represents the part of ourselves that others see, but that we don’t see (or hear). Maybe you’ve glimpsed some of your blind spot by watching yourself on video, or listening to your recorded voice, or from getting feedback from other people about how they experience you.

    The Unknown. The unknown is that mysterious part of ourselves that remains hidden to us and hidden to others.

Mostly, the Johari Window is useful as a tool for enhancing self-awareness and shrinking the Blind Spot and Unknown areas. You can think of it as getting to know the parts of ourselves that are unconscious or outside our awareness. As noted in the figure below (which I copied from this internet site: https://www.communicationtheory.org/the-johari-window-model/), there are methods for expanding self-awareness. The main method for expanding self-awareness is to ask others for feedback. Asking others, “What do you think of me?” is a powerful and straightforward self-awareness tool, but it requires social risk-taking and courage. Asking for feedback is a good, but not perfect method for expanding self-awareness because asking others for feedback may NOT expand your self-awareness if that other person doesn’t know you well or sees you inaccurately. Feedback from others is often, but not always, helpful for expanding self-awareness.

Another method for expanding self-awareness involves, ironically, being more open and transparent to others. If we want accurate feedback from others, it’s best to let others get to know us, otherwise the feedback and information they provide will be necessarily limited. To get good feedback from others, we need to provide others with good data about ourselves. Without good data, others can’t give us good feedback. See below for the Figure illustrating the Johari Window.

I’m writing about the Johari Window for educational reasons, but also because it’s a great way to introduce your Spring Break happiness assignment. This is an assignment that I made up about six years ago while teaching a career development class. I call it the Natural Talent Interview. Not surprisingly, because I made it up, I think it’s an awesome assignment that everyone will love. On the other hand, you should be the judge of that, AND, you should give me feedback on this assignment so I can expand my self-awareness!

Here’s the assignment:

Conduct Two Natural Talent Interviews: To do this assignment, identify two people whom you respect and trust. Let them know that you have an assignment to get more in touch with your personal strengths and talents. Then, get a note pad (or commit yourself to making mental notes) and ask them the following question:

What do you think are my three greatest strengths or talents?

As you’re listening, be sure to ask the person for specific examples of each talent or strength. You can take notes if you’re comfortable, or just listen and then soon afterwards document what the person said about you—both your natural talents and examples to support them.

The purpose of this assignment is to get to know your personal strengths and talents from the perspective of others. Maybe you’ve done this sort of thing before. But because things change with time, it’s worth updating the feedback you get from others or worth asking new people for feedback.

At the end, write a summary of what you learned about your natural talents and upload it to Moodle for Dan and me to read.

Thanks and happy Friday.

John S-F

 

 

Hanging out with the Virginia School Counseling Association in Richmond: The Extra Handout

Richmond Statue

I just had an awesome day with about 260 Virginia School Counselors. You know who you are, and you know you’re incredible.

Just FYI, the state of Virginia is making a big investment in adding school counselors. . . which IMHO, is a very smart and reasonable decision. Other states might want to take note and follow their lead. The problem is that many school age youth are suffering from extremely challenging home, neighborhood, and school situations. Having more competent school counselors available to support student success, student mental health, and teachers is a wise move.

For all of the VSCA members I met today, thank you for coming, but more importantly, thanks for the deeply important commitment you make to the well-being of students in your schools. You are amazing!

Here’s the extra handout, with more details than the powerpoint slides: VSCA 2020 Extra Handout

 

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.