Category Archives: Cool Counseling

The Sweet Spot of Self-Control

The Sweet Spot of Self Control (and Anger Management)

The speedometer reads 82 miles per hour. The numbers 8 and 2, represent, to me, a reasonable speed on I-90 in the middle of Montana. Our new (and unnecessary) speed limit signs read eight-zero. So technically, I’m breaking the law by two miles per hour. But the nearest car is a quarter mile away. The road is straight. Having ingested an optimal dose of caffeine, my attention is focused.

Slowly, a car creeps up from behind. He has his cruise control set at 83 mph. He lingers beside me and edges ahead. Then, with only three car lengths between us, he puts on his blinker and pulls in front of me. Now, with no other cars in sight, there’s just me and Mr. 83 mph on I-90, three car lengths apart.

An emotion rises into awareness. It’s almost anger. But nope, it not anger, it’s anger’s close cousin, annoyance. I feel it in my psyche and immediately know it can go in one of three directions: It could sit there and remain itself, until I tire of it; if I feed it, it could rise up and blossom into full-blown anger; or, I can send it away, leaving room for other thoughts and actions.

This is fabulous. This is the Sweet Spot of Self-Control.

Anger is lurking there, I know. I see it peeking over the shoulder of its cousin. “Hello anger,” I say.

In this sweet spot, I experience expanding awareness, a pinch of energy, along with an unfolding of possibilities. I love this place. I love the feelings of strength and power. I also recognize anger’s best buddy, the behavioral impulse. This particular impulse (they vary of course), is itching for me to reset my cruise control to 84 mph.  It’s coming to me in the shape of a desire—a desire to send the driver in front of me a clear message.

“You should cut him off,” the impulse says, “and let him know he should get a clue and give you some space.”

The sweet spot is sweet because it includes the empowered choice to say “No thanks” to the impulse and “See you later” to anger.

Now I’m listening to a different voice in my head. It’s smaller, softer, steadier. “It doesn’t matter” the voice whispers. “Let him creep ahead. Revenge only satisfies briefly.”

I feel a smile on my face as I remember an anger management workshop. With confidence, I had said to the young men in attendance, “No other emotion shifts as quickly as anger. You can go from feeling completely justified and vindicated, but as soon as you act, you can feel overwhelmed with shame and regret.”

A man raised his hand, “Lust” he said. “Lust is just like anger. One second you want it more than anything, but the next second you wish you hadn’t.”

“Maybe so,” I said. “Maybe so.”

There are many rational reasons why acting on aggressive behavioral impulses is ill-advised. Maybe the biggest is that the man in the car wouldn’t understand my effort to communicate with him. This gap of understanding is common across many efforts to communicate. But it’s especially linked to retaliatory or revenge-filled impulses. When angry, I can’t provide nuance in my communication and make it constructive.

The quiet voice in my brain murmurs: “You’re no victim to your impulses. You drive the car; the car doesn’t drive you.” That doesn’t make much sense. Sometimes the voice in my head speaks in analogy and metaphor. It’s a common problem. I want straight talk, but instead I get some silly metaphor from my elitist and intellectual conscience.

But I do get it and here’s what I get. I get that my conscience is telling me that this sweet spot is sweet because I get to see and feel my self-control. Not only do I get to see my behavioral options, I get to see into the future and evaluate their likely outcomes. I get to reject poor choices and avoid negative outcomes linked to aggressive actions. I’m not a victim of annoyance, anger, or aggressive impulses. I get to make the plan. I get to drive the car.

Now that other driver is far ahead.

Being on a Montana freeway, it’s hard to not think of deer. It’s clear now, but at dusk, deer will be everywhere. They have an odd instinct. Freud and my elitist conscience are inclined to call it a death instinct. Here’s how it works:

When I drive up alongside a deer on the side of the road, it dashes ahead, running alongside me; then it tries to cut across in front of me. This is the coup de gras of bad judgment. I’m in a big metal machine. The deer isn’t. So the deer dies. Not a good choice for the deer.

Yesterday, my phone alerted me to a Youtube speech by an unnamed alt right big-man. I watched and listened. So much smugness I was sick. In the end he shouted out “Hail Trump” and a few others jumped up and gave the “Heil Hitler!” salute.

Like a crazed deer, I felt an instinct. I wanted to drive to D.C. or Whitefish, Montana and find unnamed alt-right man and cut him off with some uncivil discourse. Instead, because I have a frontal lobe, I walked to the gym. Upon arriving, I discovered I’d stepped in dog poop. I’m sure this was an annoying but meaningful metaphor for something. At least that’s what my metaphor-loving conscience suggested. I didn’t buy it. Instead, I muttered “WTF” to myself. Okay, so maybe I muttered “WTF” several times. Then I walked outside in my socks and started cleaning the poop off my shoe. Not an easy task, especially if you’re wearing brand new trail-runners. I had to find a restroom near my office, an old toothbrush, lots of foamy soap, and mindfully scrub away the poop.

I was reminded of something my daughter Rylee once said at age three. She was being carried down a hill and there were many small piles of deer scat. She noticed, commenting: “I didn’t know the poop was so deep.”

Neither did I.

But the good news is that I (like you) own a functional frontal lobe that gifts me with the Sweet Spot of Self-Control. Many of us will be mindfully removing the metaphorical shit from our shoes for some time into the future. So let’s make some plans. Not revenge-laced plans; they don’t last. Yes. Let’s pause in the special sweet spot, evaluate our alternatives, and make some excellent plans.

rita-and-john-tippet

Emotional Dysregulation: Finding the Way Out

Sometimes we call it affect dysregulation. It creeps around like a metaphorical tarantula, sometimes popping up—big and frightening—and always best viewed from a distance. Just like shit, emotional dysregulation happens.

In counseling and psychotherapy, we throw around jargon. It can be more or less helpful. When it’s helpful, it facilitates important communication; when it’s not, it distances us from the experiences of our clients, students, and other mental health consumers.

So what is emotional dysregulation? Here’s what Wikipedia says:

Emotional dysregulation (ED) is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response. ED may be referred to as labile mood (marked fluctuation of mood) or mood swings.

I hereby declare that definition not very helpful.

I have a better definition. Emotional dysregulation (ED) is the term of the month. Why? Because I’ve been intermittently emotionally dysregulated since November 9 and I see emotional dysregulation nearly everywhere I look.

I’ve seen many clients for whom the term emotionally dysregulated is an apt description. These clients report being frequently triggered or activated (more jargon) by specific incidents or experiences. Many of these incidents are interpersonal, but as many of us know from the recent election, they can also be political and, for many, reading about or directly experiencing social injustice is a big trigger. After being emotionally triggered, the person (you, me, or a client) is left feeling emotionally uneasy, uncomfortable, and it can be hard to regain emotional equilibrium, calm, or inner peacefulness.

What are common emotional dysregulators? These include, but are certainly not limited to: Being misunderstood, experiencing social rejection or social injustice, harassment, or bullying, or being emotionally invalidated. Consider these (sometimes well-meaning) comments: “Smile.” “What’s wrong with you?” “You’re overreacting.” “Chill.” “Cheer up.”). One time I overheard a father tell his son, “Do you think I give a shit about what you’re feeling?” Yep. If someone says that to you or you overhear someone saying it to a 10-year-old, that might trigger emotional dysregulation.

Emotional dysregulation passes. That’s the good news. But sometimes it doesn’t pass soon enough. And other times, like when I see he-who-will-not-be-named on the television screen or hear his voice on the radio, repeated re-activation or re-triggering can occur. It becomes the Ground Hog’s Day version of emotional dysregulation.

In the clinical world, emotional dysregulation is linked to post-traumatic stress disorder, borderline personality disorder, clinical depression, and a range of other anxiety disorders. Suicidal crises often have emotional triggers. The point: emotional dysregulation is a human universal; it occurs along a continuum.

The Fantastic Four

Emotional dysregulation usually involves one of the fantastic four “negative” emotions. These include:

  • Anger
  • Sadness
  • Fear
  • Guilt

To be fair, these emotions aren’t really negative. They have both negative and positive characteristics. In every case, they can be useful, sooner or later, to the person experiencing them. For example, anger is both light and energy. It can clarify values and provide motivation or inspiration. Unfortunately, the light and energy of anger is also confusing and destabilizing. It’s easy for anger to cloud cognition; it’s easy for anger to send people out on misguided behavioral missions. Funny thing, these misguided, anger-fueled missions often feel extremely self-righteous, right up until the point they don’t. Less funny thing, immediately after the punch, the flip-off, the profanity, the broken window or door or relationship or whatever—regret often follows. Ironically then, the emotional dysregulation (anger) leads to behavioral dysregulation (aggression), which leads right back to emotional dysregulation (guilt and remorse).

Dysregulation can be experienced via any of a number of dimensions. You can experience behavioral, mental, social, and spiritual dysregulation. What fun! Who designed this system where we can get so dysregulated in so many different ways? Never mind. It was probably he-who-will-not-be-named.

One of the most perplexing things about emotional dysregulation is that so very often, we do it to ourselves. We do it repeatedly. And more or less, we usually know we’re doing it. We seem to want to embrace our anger, sadness, fear, and guilt. What’s wrong with that? Nothing, that is, until we want out.

For most people, the fantastic four feel bad. They stay too long. They adversely affect relationships. They’re bad company.

There’s one best way out of emotional dysregulation. I’ll say it in a word that I’m borrowing from Alfred Adler. Gemeinschaftsgefühl. I’ll say it in another word: Empathy. Empathy for yourself and others. The kind of empathy that moves you to being interested in other people and motivated to help make our communities and the world better, safer, and more filled with justice.

Okay then. Let’s get out there and start Gemeinschaftsgefühling around. We’ve got at least four years of work ahead.

****

For another, less profound way out of the Fantastic Four negative emotions, check out the Three-Step Emotional Change Trick: https://johnsommersflanagan.com/2012/09/23/the-three-step-emotional-change-trick/

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Using an Invitation for Collaboration in Counseling and Psychotherapy

As I’m sure you know, I believe (rather strongly) that counselors and psychotherapists should work hard to collaborate with clients. Being an authoritarian therapist is passe.

Sometimes collaboration sounds easy in theory, but it can be difficult in practice. It’s especially difficult if clients come into your office not “believing in therapy” and not trusting you. In the following excerpt from the forthcoming 6th edition of Clinical Interviewing, you can see how a skilled therapist deals with some initial client hostility.

Case Example 3.1: An Early Invitation for Collaboration

Sophia, a 26-year-old mother of two was referred for counseling by her children’s pediatrician. When she sat down with her counselor, she stated:

I don’t believe in this counseling thing. I’m stressed, that’s true, but I’m a private person and I believe very strongly that I should take care of myself and not have anyone take care of my problems for me. Besides, you look like you might be 18 years old and I doubt that you’re married or have children. So I don’t see how this is supposed to help.

It’s easy to be shaken when clients like Sophia pour out their doubts about therapy and about you at the beginning of the first session. Our best advice: (a) be ready for it; (b) don’t take it personally, Sophia is speaking of her doubts, don’t let them become yours; (c) be ready to respond directly to the client’s core message; and (d) end your response with an invitation for collaboration. An invitation for collaboration is a clinician statement that explicitly offers your client an opportunity to work together. In some cases, an invitation for collaboration is a time-limited “let’s try this out” offer.

Here’s a sample counselor response to Sophia:

Counselor: I hear you loud and clear. You don’t believe in counseling, you’re a private person, and you’re concerned that I don’t have the experiences needed to understand or help you.

Sophia: That’s right. [Sometimes when the counselor explicitly reflects the client’s core message (i.e., “. . . you’re concerned I don’t have the experience needed to understand or help you”) the client will retreat from this concern and say something like, “Well, it’s not that big of a deal.” But that’s not what Sophia does.]

Counselor: Well then, I can see why you wouldn’t want to be here. And you’re right, I don’t have a lot of the life experiences you’ve had. . But I do have knowledge and experience working with people who are stressed and concerned about parenting and I’d very much like to have a chance to be of help to you. How about since you’re here, we try out working together today and then toward the end of our time together I’ll check back in with you and you can be the judge of whether this might be helpful or not?

Sophia: Okay. That sounds reasonable.

In this case the counselor responded directly and with empathy to Sophia and then offered an invitation for collaboration. As the session ends, Sophia may or may not accept the counselor’s invitation. But either way, the counselor’s skillful response provides an opportunity for a collaborative relationship to develop.

Round Bales

 

A Brief History and Analysis of Antidepressant Medication Treatment for Youth with Depression Diagnoses

The popular press intermittently acts surprised that antidepressant medications actually have little scientific evidence supporting their efficacy. It’s old news, but it’s still important news and I’m glad for the recent reports. See: http://www.everydayhealth.com/news/did-studies-lack-key-data-on-link-between-antidepressants-youth-suicides/

Rita and I published an article about this in 1996. Below, I’ve pasted a pre-print excerpt from an article I published with Duncan Campbell in 2009 in the Journal of Contemporary Psychotherapy. It includes a brief summary of antidepressant medication research through 2008 or so. Check it out:

A Brief History and Analysis of Antidepressant Medication Treatment for Youth

Medication treatment for depressed youth has evolved over three relatively distinct periods. First, prior to 1987, small exploratory studies examined tricyclic antidepressant (TCAs) efficacy with young patients diagnosed with major depressive disorder (MDD). Second, from 1987-1994 there were a number of randomized, controlled trials (RCTs) of TCA efficacy; these efforts often employed double-blind procedures and inactive placebo controls. Third, since 1997, research efforts have primarily focused on evaluating selective serotonin reuptake inhibitor (SSRI) efficacy with RCTs.

Early Research: Pre-1987

In the early 1980s, psychiatric and pharmaceutical researchers began testing TCAs with youth. Early conclusions about the safety and efficacy of TCAs were generally optimistic (Klein, Jacobs, & Reinecke, 2007). This is a tendency that has been identified in the literature and it may be due to methodological limitations, confirmation bias or an allegiance to the medical model, or financial incentives associated with the pharmaceutical industry (Klein et al., 2007; Luborsky et al., 1999). For example, on the basis of existing studies and their very small double-blind trial with nine prepubertal children, Kashani and colleagues (1984) concluded that amitrityline was possibly efficacious for treating depression in children. Interestingly, the authors’ tentative claim was made despite the fact that no statistically significant effect was observed for amitriptyline and even though 11% of their sample “developed a hypomanic reaction while on the protocol” (p. 350).

RCTs with TCAs

From 1965 to 1994 there were 13 published RCTs evaluating TCA efficacy. Most of these studies were conducted from 1987 to 1994 (Fisher & Fisher, 1996; Sommers-Flanagan & Sommers-Flanagan, 1996). These RCTs confirmed the premature hopefulness of Kashani and colleagues’ early claims. Indeed, no study ever published showed that TCAs outperformed placebo in the treatment of youth depression (Hazell, 2000). More importantly, it is currently recognized that TCAs possess dangerous side effect profiles, while offering no demonstrable advantage over placebo in the treatment of youth depression (Hazell, 2000; Pellegrino, 1996).

In the mid-1990s there was considerable speculation about why TCAs were ineffective for treating youth. The primary hypothesis for involved the fact that children appear to have immature adrenergic synaptic systems. This possibility precipitated a more systematic inquiry of serotonergic medications.

RCTs with SSRIs

Using PsychInfo and PubMed searches combined with cross-referencing, we identified 12 published RCTs evaluating SSRI efficacy with 11 of these studies from 1997 to 2007. In total, these studies compared 1,223 SSRI treated patients to a similar number of placebo controls. On the basis of the researchers’ own efficacy criteria, six RCTs observed outcomes favoring medication over placebo, and six observed nonsignificant differences. Researchers described efficacious outcomes for fluoxetine (3 of 4 studies; G. J. Emslie et al., 2002; G. J. Emslie et al., 1997; Simeon, Dinicola, Ferguson, & Copping, 1990; Treatment for Adolescents With Depression Study (TADS) Team, US, 2004), paroxetine (1 of 3; Berard, Fong, Carpenter, Thomason, & Wilkinson, 2006; G. Emslie et al., 2006; M. B. Keller, 2001), sertraline (1 of 1; K. D. Wagner et al., 2003), and citalopram (1 of 1; K. D. Wagner et al., 2004). Neither of two studies observed efficacy for venlafaxine (G. J. Emslie, Findling, Yeung, Kunz, & Li, 2007; Mandoki, Tapia, Tapia, & Sumner, 1997), and the single escitalopram study returned negative results (K. D. Wagner, Jonas, Findling, Ventura, & Saikali, 2006).

Methodological Issues

Assessing a medication’s efficacy is a complex process with challenges that are difficult to address. We believe, however, that the six aforementioned RCTs favoring SSRIs suffered from methodological problems and issues that temper their positive conclusions. For example, (a) two of the three fluoxetine studies were characterized by unusually high and disproportionate discontinuation rates in the placebo conditions; (b) 11 of the 12 studies based their conclusions exclusively on a structured psychiatric interview; (c) despite simultaneous examination of several outcomes, no study used statistical adjustments for multiple comparisons; (d) placebo washouts and statistical approaches that advantage medications were nearly always employed (R. P. Greenberg, 2001); (e) no procedures were used to evaluate double-blind integrity (R. P. Greenberg & Fisher, 1997); and (f) despite documented inter-racial differences in medication metabolism and responsiveness, conclusions were generalized to all youth and inappropriately failed to account for racial/cultural specificity (Lin, Poland, & Nakasaki, 1993).

Side Effects and Adverse Events

In RCTs and other studies, patients treated with SSRIs experienced substantially more disturbing side effects and adverse events than those not treated with SSRIs. For example, in one of the most rigorous studies to date, the Treatment of Adolescents with Depression Study (TADS), 11.9% of the fluoxetine group evidenced harm-related adverse events (compared to 4.5% in the Cognitive Behavioral Therapy [CBT] group) and 21% experienced psychiatric adverse events (1% in the CBT group). Further, as the authors noted, “…suicidal crises and nonsuicidal self-harming behaviors were not uncommon and, with the caveat that the numbers were so small as to make statistical comparisons suspect, seemed possibly to be associated with fluoxetine treatment” (March et al., 2006; The TADS Team, 2007 p. 818; Treatment for Adolescents With Depression Study (TADS) Team, US, 2004).

Findings like these necessitate critical inspection of study results and should attenuate positive conclusions about medication safety. For example, Emslie et al.’s (1997) study of youth depression was the first ever to demonstrate superior outcome for an SSRI. In addition to the study’s numerous methodological problems, the authors noted that 6.3% of the fluoxetine patients (n = 3) developed manic symptoms. Although this percentage may sound small, extrapolation suggests that 6,250 of every 100,000 fluoxetine-treated youth might develop manic symptoms. Ultimately, despite data based solely on psychiatrist ratings and a placebo condition discontinuation rate approaching 46%, the authors concluded that fluoxetine “…is safe and effective in children and adolescents with MDD” (p. 1037). Moreover, the authors’ intent-to-treat analysis possibly conferred an advantage for the active drug group. In our opinion, this methodological problem and the mania data make it premature to conclude that fluoxetine is safe and effective in children.

Similarly, despite striking data that appear to demonstrate otherwise, authors of the single positive paroxetine study concluded that paroxetine is “safe and effective” for young patients (M. B. Keller et al., 2001). However, in their results section, the research team reported serious adverse effects, “…in 11 patients in the paroxetine group, 5 in the imipramine group, and 2 in the placebo group” (p. 769). More specifically, five adverse effects in the paroxetine group involved suicidal ideation or gestures. Despite these data, the researchers presented their results as evidence for the efficacy and safety of paroxetine treatment for adolescent depression. Because 12% of the paroxetine-treated adolescents experienced at least one adverse event and because 6% of these patients manifested increased suicidality or suicidal gestures (compared with zero in the imipramine and placebo groups), we believe the authors’ conclusion departs from the data in a significant and concerning way.
Shortly after publication of the Keller et al. (2001) study, regulatory agencies in France, Canada, and Great Britain restricted SSRI use among youth. In September of 2004, an expert panel of the U.S. Food and Drug Administration (FDA) followed suit and voted 25-0 in support of an SSRI-suicide link. Later, the panel voted 15-8 in favor of a ‘black box warning’ on SSRI medication labels. The warning states:

“Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of Major Depressive Disorder (MDD) and other psychiatric disorders. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.”

In 2006, the FDA extended its SSRI suicidality warning to adult patients aged 18-24 years (United States Food and Drug Administration, 2007).

Combination Medication and Psychotherapy Treatments

Many view the 2004 TADs study as a ‘state of the science’ comparison of SSRI medication (fluoxetine; FLU) with CBT and their combination (FLU + CBT). To date, it represents the largest placebo-controlled study comparing mono-therapy (FLU or CBT alone) with combination therapy. Not surprisingly, the TADs study has generated numerous publications and much controversy (Antonuccio & Burns, 2004; Diller, 2005; Weisz, McCarty, & Valeri, 2006).

To summarize, initial 12-week outcomes showed that 71% of FLU + CBT patients evidenced “much” or “very much” improvement on the on the CGI-Improvement item, a clinician-based assessment. FLU alone produced a similar outcome (60.6%), whereas the CBT alone (43.2) outcome did not differ significantly from placebo (34.8%). Based on these outcomes, several CBT researchers and practitioners criticized the specific CBT delivered to TADs participants. Brent (2006), for example, described TADS psychotherapy as a relatively “dense treatment, with multiple CBT strategies, each delivered at a relatively low dose” (p. 1463). In comparing the initial TADs CBT outcomes with previous and subsequent CBT studies, Weisz et al. (2006) suggested that the TADs CBT was weaker than most CBT interventions, for various reasons:

“the CBT ES (effect size) generated in TADS is not characteristic of most CBT or psychotherapy effects on youth depression; 20 of the 23 other CBT programs. . . showed larger ES than the TADS version of CBT, and the mean ES value across the non-TADS CBT programs. . . was 0.48, markedly higher than the -0.07 ES associated with the TADS CBT intervention” (p. 147).

To complicate issues further, follow-up data suggest that the TADs CBT evidenced delayed effectiveness, as it eventually “caught up” with FLU and CBT+FLU (The TADS Team, 2007). At week 18, for example, there were no statistically significant differences between CBT and FLU, and by week 36 there were no statistical differences among the three groups (CBT, FLU, and CBT + FLU) on primary outcome measures. Although the interventions including FLU might evidence a speedier antidepressant effect, these results suggest that CBT is equally effective over time.

The depression treatment literature frequently includes recommendations for combined interventions in order to maximize outcomes (Watanabe, Hunot, Omori, Churchill, & Furukawa, 2007). Unfortunately, however, little data exists to support these recommendations. In addition to TADs, the only other published RCT comparison of mono- and combination treatments for depressed adolescents reported partial remission rates of 71% for CBT, 33% for sertraline, and 47% for combination (Melvin et al., 2006). Medication group patients also evidenced significantly more adverse events and side effects. Although the researchers attributed the delayed response in the combination group to sertraline, they concluded with the puzzling statement that “CBT and sertraline are equally recommended for the treatment for adolescents with depression, each demonstrating an equivalent response” (Melvin et al., 2006 p. 1160).

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Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

This is a rough preview of a section from the 6th edition Clinical Interviewing. As always, your thoughts and feedback are welcome.

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

Research on how to practice with culturally diverse youth is especially sparse. To make matters more complex, youth culture is already substantially different from adult culture. This means that if you’re different from young clients on traditional minority variables, you’ll be experiencing a double dose of the cultural divide. These complications led one writer to title an article “A knot in the gut” to describe the palpable transference and countertransference that can arise when working with race, ethnicity, and social class in adolescents (Levy-Warren, 2014).

To help reduce the size of the knot in your gut, we’ve developed a simple research- and common-sense list to guide your work with culturally diverse youth (Bhola & Kapur, 2013; Norton, 2011; Shirk, Karver, & Brown, 2011; Villalba, 2007):

1. Use the interpersonal skills (e.g., empathy, genuineness, respect) that are known to work well with adult minority group members. Keep in mind that interpersonal respect is an especially salient driver in smoothing out intercultural relationships.

2. Find ways to show genuine interest in your young clients, while also focusing on their assets or strengths.

3. Treat the meeting, greeting, and first session with freshness and eagerness. There’s evidence that young clients find less experienced therapists easier to form an alliance with.

4. Use a genuine and clear purpose statement. It should capture your “raison d’etre” (your reason for being in the room). We like a purpose statement that’s direct and has intrinsic limits built in. For example: “My goal is to help you achieve your goals . . . just as long as your goals are legal and healthy.” One nice thing about this purpose statement is that sometimes young clients think the “legal and healthy” limitations are funny.

5. Don’t use a standardized approach to always talking with youth about your cultural differences. Instead, wait for an opening that naturally springs up from your interactions. For example, when a teen says something like, “I don’t think you get what I’m saying” it’s a natural opening to talk about how you probably don’t get what the youth is saying. Then you can discuss some of your differences as well as you’re desire to understand as much as you can. For example: “You’re right. I probably don’t get you very well. It’s obvious that I’m way older than you and I’m not a Native American. But I’d like to understand you better and I hope you’ll be willing to help me understand you better. Then, in the end, you can tell me how much I get you and how much I don’t get you.”

6. Provide clear explanations of your procedure and rationale and then linger on those explanations as needed. If young clients don’t understand the point of what you’re doing, they’re less likely to engage.

7. Be patient with your clients; research with young clients and diverse clients indicate that alliance-building (and trust) takes extra time and won’t necessarily happen during an initial session

8. Be patient with yourself; it may take time for you to feel empathy for young clients who engage in behaviors outside your comfort zone (e.g., cutting)

I hope these ideas can help you make connections with youth from other cultures. The BIG summary is to BE GENUINE and BE RESPECTFUL. Nearly everything else flows from there.

The 2015 Counselor Education Graduation Speech I Didn’t Give

This is the transcript of the 2015 Graduation Speech for Counselor Education I didn’t give. I should note, I wasn’t really invited to deliver a speech, but since I’m in Absarokee and can’t attend graduation, I’m pretending this is the speech I would have given. In other words, I’m making all this up.

The Speech

Graduation speeches are supposed to be lightly profound with a substantial dose of inspiration. Well . . . this one, not so much.

Seriously? Like you didn’t know this speech would be different?

After all, two years ago (or maybe three or four years ago for some of you who are extra special), you all enrolled in a graduate program in . . . COUNSELING. Basically, what I’m saying is that something in your rational brain snapped and you let an empathic, compassionate, impulse to help others for the rest of your life take over and start making your BIG life decisions for you. You know you did. And your family and friends know you did. I’m just naming the elephant in the room by saying it in public

I’m proud to say that I’m proud of you for that. And this is coming from someone who basically hates and avoids the word proud. That’s partly because pride is one of the seven deadly sins and it goeth before a fall and all that. I just thought you should know how hard it was for me to say that I’m proud of you . . . which makes me think in my head that I almost feel a little proud of myself, which I would never, of course, say out loud, which I’m not doing now because if there’s anything I certain of, I’m certain that you can’t hear my thoughts.

But what I am saying is that I’m glad you made the decision to forsake nearly all of the materialistic messages given to you, heretofore (I really like saying things like heretofore, especially during graduation speeches), by contemporary society. Just think, if everyone went down the evil road of materialism we wouldn’t even have graduate programs in counseling where people like you spend good money to learn how to listen well and help others, while not making very much bank. You know what I’m talking about.

My point is, you’re just DIFFERENT and unless your faculty forgot to tell you, you should know that by now. And my other point is: that’s why you should have known this would be YET ANOTHER LECTURE and not some sappy, emotionally inspiring speech. And the reason for this is that in the business you’ve chosen to practice . . . learning NEVER ENDS . . . and so I don’t want to give any of you the wrong impression that somehow graduating means you get to stop learning. You don’t. I’m here to tell you that.

This leads me to my lecture, the title of which is something like:

Everything I Should Have Taught You Over the Past Several Years,

But Because You All Talked Way Too Much In Class I Didn’t Have Time.

And I should mention that this lecture could take anywhere from a few minutes to several days. Please. There’s no need to thank me. You’ve earned this.

Let’s start with you taking notice of the imprecision I used in stating my lecture title. I said, “. . . something like.” This is our first and most important lesson for the day. When it comes to counseling humans, we shouldn’t fool ourselves into thinking we can be precise. This is why you chose to study with us touchy-feely-counseling types over here in the College of Education instead of running over with your calculators to psychology where you could be a scientist (at this point in the speech I’m making an enigmatic face that makes you wonder if I’m praising psychology as a science or making fun of psychology for just having lots of irrational cognitions about being a science). This is why you set collaborative goals in counseling and not unilateral goals.

As Salvadore Minuchin said a couple of decades ago at a workshop here in Missoula, “Don’t be too sure.” I like that message.

And now although I’m not too sure about whether what I’ve got planned next is a good idea, it’s something I feel compelled to teach you. After all, prior to this last year’s holiday party, when there was an opportunity for Karaoke and, in the humble way that you’ve come to know as characteristic of me, I sent you all an email explaining that I had co-invented Karaoke in 1973 in Mike Bevill’s basement and consequently was happy to provide everyone with Karaoke lessons, the response was COMPLETE EMAIL SILENCE. Consequently, how could I not conclude that either you (a) have debilitating Karaoke anxiety, or (b) have low Karaoke-esteem, or (c) are uninformed as to the benefits of Karaoke, or (d) all of the above, or (e) only a and b?

Hopefully you got the answer to that rhetorical question correct, because here comes the Karaoke lesson.

OLYMPUS DIGITAL CAMERA
OLYMPUS DIGITAL CAMERA

Of course, before I start, as I like to say in my classes and workshops, you can always pass on this experience and if you so choose, please do so by doing what many of my teenage clients do – ignoring me – which may or may not involve you placing your hands over your ears and humming or laying your head on your arm and snoring.

The first rule of Karaoke is, as the late Bill Glasser would have said—had he ever had the good sense to lecture on Karaoke—“Your goal should be within your personal control.”

This rule has several implications, but most importantly, it speaks to song and wardrobe selection. Specifically, you always want to select a Karaoke song that’s within your range and within your wardrobe. I cannot emphasize this enough. For example, although I very much like the song . . . “This Girl is on Fire” I tried singing it and it didn’t go well.

As you can infer from the photo below, choosing the wrong song can be embarrassing and beyond your control. Don’t do it . . . unless it’s part of your shame- attacking treatment plan.

Peg and John Singing at Pat's Wedding

So, obviously, pick a song that fits your voice and your gender stereotypes.

The second rule is all about song lyrics and so I’ve made up another rhyme to help you auditory learners remember. That is, “To function to the best of your ability, you should embrace your multicultural humility.”

What I’m saying here is that, as you know, many pop songs have lyrics that are racist, sexist, and sexually explicit. To maintain our multicultural sensitivity (and humility), it’s important to either (a) avoid songs with insensitive or sexualized lyrics (which is why I never sing Lady Gaga’s song that includes the line about her not bluffin’ with her muffin) or (b) change the lyrics on the spot (for “Say a Little Prayer for You” I like to substitute, “Do a little non-denominational mindfulness meditation for you.” It works fine, you just have to say the words very quickly) or (c) just mumble when the offending lyrics appear.

The third rule can also be captured with a nifty, easily memorized rhyme: “An alcoholic drink, will not help you think.” It also won’t improve your judgment or make you look more impressive to your audience. I hope what I’m saying here is clear. Just like when you’re providing professional counseling, when doing Karaoke, it’s best to be squeaky clean and sober. I should add, contrary to popular belief, drinking alcohol will NOT MAKE YOU A BETTER DANCER. Although the caveat to this is that if OTHERS are drinking alcohol during your performance, it might make them THINK you’re a better dancer.

The corollary to this rule is that evidence-based Karaoke-ers use dancing to optimize their performance. This probably goes without saying, but I’ll say it anyway, “Be solution-focused and go with your strengths!” If your voice is bad or the lyrics are bad or you’re so nervous you’ve lost your ability to read, DANCE BIG. I did this a few years ago when I planned a rap to the Simon and Garfunkle tune “Feeling Groovy” and it quickly became obvious that the audience mostly wanted to watch my radical rapping dance moves and so I just went with that. The fact that no one at that party will talk to me anymore is irrelevant. I think it’s mostly because I intimidated the heck out of them and so they’re afraid to approach me now. I should note that this is a particular cognition that my counselor and I decided I shouldn’t test . . . so I’m just going with it. Here’s a photo of that performance. Apparently all the video recordings were lost or burned.

John Rap

The fourth and final Karaoke rule is this: “A pill is not a skill . . . but Karaoke is a thrill.” What this means is that if you want to grow up to be a bad-ass Karaoke singer like me, then you have to practice, practice, and then practice some more . . . because as they say about counseling and counselors, all we ever do is practice.

There is no final performance.
There is no end to your learning.
And this is not my final goodbye to you.

I will be thinking of you all and wishing and hoping you the best success in whatever you choose to practice, knowing that I’ve had the excellent fortune and gift of time with you and that I’ve come to believe deeply in your ability, skill, compassion, and character.

One time when I was working with a dad and his son in counseling, the dad got right in his son’s face and delivered him a message that he would never forget. And so I want to end by sharing that message with you in hopes that you will hear it over-and-over in your brain:

“I will always be proud of you.”

Thanks for listening. Thanks for reading. Thanks for watching.

And thanks for being different.

P.S. I’m available for Karaoke tutoring and supervision and I can show you some hand movements, that, in particular, will blow your mind and insure an unforgettable Karaoke experience.

Secrets of the Miracle Question

This is a re-post from the American Counseling Association Blog.

You might want to sit down because this could take a while.

Developed in the 1970s by Insoo Kim Berg and Steven de Shazer, the miracle question has become a very popular therapy intervention. It’s standard fare for solution-focused therapists and has been written about extensively. In 2004, Linda Metcalf wrote a whole book about it and in 2010 Ryan Howes of Psychology Today declared it the #10 most “cool” intervention in psychotherapy.

To be honest, I have mixed feelings about the miracle question. Although I’ve used it with clients and found it helpful, I’ve never found it the least bit miraculous. It’s a good and clever question that helps clients focus on goals. But it’s no miracle.

My biggest problem with this intervention is the use of the word miracle. Miracles are, by definition, highly improbable, highly desirable, not explained by natural causes, and typically ascribed to divine intervention. Wow. That IS cool…

Using the word miracle to describe a common goal-setting question is excellent marketing. The only thing better might have been to call it the secret miracle question. But as I write this I hear the voice of Rich Watts in the back of my head muttering something about how everybody steals the work of Alfred Adler without giving him credit. Rich is President of the North American Society for Adlerian Psychology. My inner Rich Watts voice is noticing that the miracle question looks a lot like “The Question,” an intervention used and written about by Alfred Adler in the early 1900s. Adler’s version went: “How would your life be different if you no longer had this problem?” Again, good question, but no miracle. And hardly anyone (other than Rich Watts and his Adlerian buddies) ever mention The Question anymore.

If I dig a little deeper, what I find most problematic is that the word miracle leads counseling students and practitioners to adopt one or more of three false beliefs. They begin believing that the miracle question is: (a) a simple procedure, (b) easy to learn and implement, and (c) that it can result in a miracle. Sadly, none of these beliefs are true.

An example from popular literature might help. Think about how long it took Harry Potter to learn the Tarantallegra spell. In case you can’t recall, the Tarantallegra spell forces one’s opponent to dance. I don’t know long it took the fictional Harry Potter to learn the fictional Tarantallegra spell, but I’m certain that even in the fictional world created by J. K. Rowling it wasn’t during his first year at Hogwarts.

The miracle question name erroneously implies something quick and easy and miraculous is happening. Sort of like snapping your fingers and reciting that Tarantallegra incantation. You can try it that way, but it won’t work…because you won’t be manifesting an understanding of the incantation. I’ve seen novice counselors try the miracle question and the most common client response elicited is: “I don’t know.” This is because counseling miracles require sophisticated language and delivery skills, a solution-focused mindset, and education and experience.

The miracle question is all about sophisticated verbal behavior. We should recall that Berg and de Shazer were strongly influenced by the renowned hypnotherapist, Milton Erickson. This is one reason why, when done well, the miracle question resembles a hypnotic induction. Even de Shazer and his colleagues noted that it might take an entire therapy session to ask and explore the miracle question (see the book, More Than Miracles).

Although many published variants of the miracle question exist, below I’m including a detailed version, as described by Insoo Kim Berg and Yvonne Dolan in Tales of Solutions. As you read through this example, remember: The miracle question should be spoken slowly, there should be repeated pauses, and the therapist should deeply believe in the solution-focused principle that all clients already possess the inherent competence to produce positive changes in their lives. Here’s the question:

I am going to ask you a rather strange question [pause]. The strange question is this: [pause] After we talk, you will go back to your work (home, school) and you will do whatever you need to do the rest of today, such as taking care of the children, cooking dinner, watching TV, giving the children a bath, and so on. It will become time to go to bed. Everybody in your household is quiet and you are sleeping in peace. In the middle of the night, a miracle happens and the problem that prompted you to talk to me today is solved! But because this happens while you are sleeping, you have no way of knowing that there was an overnight miracle that solved the problem [pause]. So, when you wake up tomorrow morning, what might be the small change that will make you say to yourself, “Wow, something must have happened—the problem is gone!” (Berg & Dolan, 2001, p. 7, brackets in original)

If you’re by yourself, you might want to go back and read through the miracle question again. This time read it aloud. Think of a small problem of your own and freely insert a few references to it.

Technically, the miracle question is a projective or generative assessment tool and hypnotic induction strategy. This is because it asks clients to project themselves into the future and generate information or scenarios straight from their imaginations. Together, counselor and client create a virtual reality and then try to make it a real reality. This is where I agree with fans of the miracle question: That’s one cool intervention. It makes me want to dance.