Category Archives: Cool Counseling

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’m 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 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.

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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,” but 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. And you can thank Dr. Albert Ellis for building you a personalized 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 also 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.

Non-Drug Options for Dealing with Depression

Evidence supporting the efficacy of antidepressant medications continues to be weak. That doesn’t mean they never work; some individuals with depressive symptoms find them very helpful and that’s okay. But for many, antidepressant meds just don’t work very well . . . there are side effects and less than desirable antidepressant effects. This is why many people wonder: What are some of the best non-drug alternatives for treating symptoms of depression?

Here’s a short list that might be helpful.

1. Counseling or Psychotherapy: Going to a reputable and licensed mental-health professional who offers counseling or psychotherapy for depression can be very helpful. This may include individual, couple, or family therapy.

2. Vigorous aerobic exercise: Consider initiating and maintaining a regular cardiovascular or aerobic exercise schedule. This could involve a specific referral to a personal trainer and/or local fitness center (e.g., YMCA). In a recent small study of adolescents with clinical depression, 100% of the teens in the aerobic exercise group no longer met the diagnostic criteria for depression after receiving several months of exercise treatment.

3. Herbal remedies: Some individuals benefit from taking herbal supplements. In particular, there is evidence that omega-3 fatty acids (fish oil) and St. John’s Wort are effective in reducing depressive symptoms. It’s good to consult with a health-care provider if you’re pursuing this option.

4. Light therapy: Some people describe great benefits from light therapy. Specific information on light therapy boxes is available online and possibly through your physician.

5. Massage therapy: Research indicates some patients with depressive symptoms benefit from massage therapy. A referral to a licensed massage therapy professional is advised.

6. Bibliotherapy: Research indicates that some patients benefit from reading and working with self-help books or workbooks. The Feeling Good Handbook (Burns, 1999) and Mind over Mood (Greenberger and Padesky, 1995) are two self-help books used by many individuals.

7. Post-partum support: There is evidence suggesting that new mothers with depressive symptoms who are closely followed by a public-health nurse, midwife, or other professional experience fewer post-partum depressive symptoms. Additionally, new moms and all individuals suffering from depressive symptoms may benefit from any healthy and positive activities that increase social contact and social support.

8. Mild exercise and physical/social activities: Even if you’re not up to vigorous exercise, you should know that nearly any type of movement is an antidepressant. These activities could include, but not be limited to, yoga, walking, swimming, bowling, hiking, or whatever you can do! In the same exercise study mentioned above, 71% of the teenagers in the mild exercise group experienced a substantial reduction in their symptoms of depression.

9. Other meaningful activities: Never underestimate the healing power of meaningful activities. Activities could include (a) church or spiritual pursuits; (b) charity work; (c) animal caretaking (adopting a pet); and (d) many other activities that might be personally meaningful to you.

The preceding list is adapted from a tip-sheet in our book, “How to Listen so Parents will Talk and Talk so Parents will Listen.” See: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_9?s=books&ie=UTF8&qid=1413432346&sr=1-9
Or: http://lp.wileypub.com/SommersFlanagan/

John and his sister working on their positive emotions.

Peg and John Singing at Pat's Wedding

 

How to Listen so Parents will Talk: Strategies for Influencing Parents — DVD filming with Alexander Street Press

This past week I was in Chicago to be filmed doing three 15 minute TED Talk like speeches for Alexander Street Press. The experience was both exciting and anxiety-provoking. . . as it’s rather challenging to deliver a 15 minute piece in a darkish studio to a camera on one take. Shannon Dermer of Governor’s State University was the smooth as silk facilitator who conducted 15 minute interviews after each speech. I was lucky enough to be filming on the same day as Paul Peluso of Florida Atlantic University. Although it was comforting to see that Paul was just as nervous as I was, it was not comforting watching him absolutely nail a perfect 10 of a presentation on Humor in Psychotherapy just a couple hours before it was my turn in front of the camera.

In the end, the filming went well, but of course during the live filming my imperfect memory led me to miss a few “lines” and so I’m posting here, a text version of the How to Listen so Parents will Talk THERAPY talk.Although my goal was to post an audio version, WordPress has thwarted that particular plan for now. . . sorry about that.

How to Talk so Parents will Listen: Strategies for Influencing Parents

When I talk with large groups about parenting, I like to begin with a survey. I ask: “How many of you ARE parents?” Of course, nearly everyone raises his or her hand. Then I ask a follow up: “How many of you WERE children.” At this question some participants laugh and a few raise their hands and others joke that they’re still immature.

“This reason I start with this survey is because if you’re a parent, you know that being a parent is an amazing and gratifying challenge. You also know that it’s 24-7; and you know it doesn’t end when your child turns 18. You’re a parent for life. And if you WERE a child, and all of you were, then you know how important it is to have a parent or caretaker who makes it perfectly clear that YOU ARE LOVED. But there’s more. If you were a child, then you also know how important it is to have a parent who not only loves you, but who is skillful . . . a parent who is dedicated to being the best parent possible.

Plain and simple: PARENTS NEED SKILLS FOR DEALING WITH THEIR CHILDREN IN THE 21ST CENTURY. And learning to be a better parent never stops.

Once upon a time I had a mom come consult with me about her five year old son. She said: “I have a strong-willed son.” My response was to acknowledge that lots of parents have strong-willed children. She said, “No, no, you don’t get it. I have a very strong-willed son, let me tell you about it. Just the other night, I asked him to go upstairs and clean his room and he put his hands on his hips and said, “NO.” So I said in response, “Yeah, yeah. He sounds very strong willed.” And she said, “Wait. There’s more. I asked him to clean his room a second time and he glared and me, and said “NO. YOU WANT A PIECE OF ME?” Then she told me the real problem. The problem was that, in fact, she did want a piece of him at that particular point in time and so she grabbed him and hauled him up the stairs in a way that was inconsistent with the kind of parent she wanted to be.

This is one of the mysteries of parenting. How can you get so angry at a small child whom you love more than anything else in the world?

Parents are a unique population and deserve an approach to counseling that’s designed to address their particular needs. In this talk I’ll mostly be using stories to talk about
a. what parents want for their children
b. what parents need in counseling
c. and how professionals can be effective helpers.

Most parents want some version of the same thing: To raise healthy and happy children who are relatively well-adjusted. But what do parents need in counseling. WHAT WILL HELP THEM GET WHAT THEY WANT?

First, parents need empathic listening. They need this big time. Our American culture puts lots of social pressure on parents . . . It’s implied that parenting should be easy and all parents should want to spend 24-7 with their child in an altered state of parental bliss. But this isn’t reality and so we need empathy for the general scrutiny parents feel in the grocery store, at church, on the playground, and everywhere else.

But they also need listening and specific empathy: like in the situation where the mom wanted to tell me about her 5-year-old son. She had specific information to share and it was really important for me to take time to listen to her unique story about her son who, unfortunately, may have been watching too many Clint Eastwood movies.

Parents come to counseling or parent education feeling simultaneously insecure and indignant. They feel insecure because of the scrutiny they feel from their parents and in-laws and society, but they also feel indignant over the possibility that anyone might have the audacity to tell them how to parent their children. As professionals, we need to be ready to handle both sides of this complex equation.

Another thing parents have taught me over the years is to never start a parenting session by sharing educational information. You should always wait to offer educational advice, even when parents ask you directly for it. When they do ask, let them know that your ideas will be more helpful later once you get to know what’s happening in their family.

This leads us to the second crucial part of what parents need in counseling. They need collaboration. We can’t be experts who tell parents what to do, instead we have to recognize that parents are the experts in the room. They’re the experts on their children, on their family dynamics, and on themselves. If we don’t engage and collaborate with parents, very little of what we offer has any chance of being helpful.

Parents also need validation to counter their possible insecurity. We call this radical acceptance or validation and it involves explicitly and specifically giving parents positive feedback. We do this by affirming, “You sure seem to know your daughter well.” And by saying, “When I listen to how committed you are to helping your son be successful in life, I can’t help but think that he’s lucky to have you as a parent.”

And so we begin with empathic listening and we move to collaboration and we make sure that we offer radical acceptance or validation and we do all this so we can get to the main point: providing parents with specific parenting tips or guidance.

And there are literally TONS of specific parenting tips that professionals can offer parents. Most of the good ones include four basic principles:

First, getting a new attitude – because developing parenting skills requires a courageous attitude to try things out.

The second one involves making a new and improved plan. Because a courageous attitude combined with a poor plan won’t get you much.

Third is to get support when you need it. Parenting in isolation is almost always a bad idea.

Fourth, underlying all tips there should be the foundation of being consistently loving.

I’d like to tell two parenting stories to illustrate all of the preceding ideas.

This first story is about a parenting struggle I had. I share it for two reasons: One is that it’s a great example of the need for parents to make a new plan to handle an old problem. And two, often it’s good to self-disclose—but not too much—when working with parents.

When my youngest child was 5-years-old, she ALSO was a strong-willed child. I vividly recall one particular ugly scene on the porch. It was time for us to leave the house. But we lived in Montana and there was snow and my daughter needed to put her boots on. Funny thing, she was on a different schedule than I was. This created tension and anger in me. And so I got down into her face and I yelled GET YOUR BOOTS ON! And her eyes got big and she did. Later that evening I was talking with my wife and she saw the scene and she said to me, “I know John, that’s not the kind of parent you want to be.” And even though it’s not easy to take feedback from our romantic partners, she was right and so obviously so, that I had no argument” which led me to tell her, “I’m not going to yell at our daughter any more. I am, instead going to whisper, because I learned in a parenting book, that sometimes when you’re angry it’s more effective to whisper than it is to yell. That was my new plan. Of course, like new plans everywhere, it needed tweaking. But it didn’t take long for me to have an opportunity to test it because if there’s anything on the planet that’s predictable, it’s that we’ll all soon have another chance to manage our anger toward our children more constructively.

It was the next day or week and my daughter did not get her boots on and she was not on the same schedule as me and I got down in her face, once again, but I remembered the plan to whisper and I did my best to transform my anger from the historical yell to the contemporary whisper and what happened was that what came out was sort of like the exorcist and I said to my daughter: “GET YOUR BOOTS ON!”

Now. I wasn’t especially proud of that, but she got her boots on.

It was the beginning of a big change for me because I learned I could play the exorcist instead of yelling; then I learned to growl and then I learned to count to three and then I learned a cool technique called Grandma’s rule where you use the formula, WHEN YOU, THEN YOU to set a limit and build in a positive outcome. Like . . . “Honey, when you get your boots on, then you can have your cell phone back.” Very cool.

What I learned from this experience is that I could be more than a one-trick parenting pony. I became the kind of parent who, although far from perfect, was able to set limits that were in my daughter’s best interest.

And what I like the best about this particular story is that daughter is now 26 years-old and she still says the same thing she used to say to me when she was 15 . . . that is, “Dad, one thing I really love about you is you never yell.” What’s cool is that I did yell, but I worked on it, I made a new plan, and now she doesn’t even remember the yelling.

I’d like to finish with one last story about how much parents need people like you to have empathy, collaborate, validate, and offer concrete parenting ideas.

I was working with a 15-year-old boy. His mom was bringing him to counseling because he and his dad weren’t speaking anymore. I hadn’t met the dad, but one day, when I went to the boy’s IEP meeting at school the dad was there. I saw this as a chance to make a connection and get him to come to counseling.

I did a little chit-chatting and sat next to him in the group meeting. Then, at one point, I asked the boy a question: “If you got an A on a test, who would you show first?” He answered, “I’d show my dad, my mom, and my special ed teacher.” This inspired me to turn to his dad and say, “It’s obvious that you’re very important to your son and so I’d like to invite you to come join him and me in counseling.” Dad gave me a glare and pushed my shoulder and began a 2-minute rant about how the school had failed his son. Everyone was stunned and then he turned back to me and said, “I’ll come to counseling. I been to counseling before and I can do it again.”

At that point I wondered if I could take back my offer.

The day the dad drove to counseling he and his son weren’t speaking, so I met with them separately. The son was clear that he would never speak to the dad again, but the dad was open. When I asked if I could offer him some ideas, he said, “Well I tried MY best and that dog don’t hunt, so I can try something else.” I was wishing for subtitles.
I told the dad I wanted him to keep his high standards for his son, but to add three things. First, I asked, do you love your son? The dad said “Yes” and so I told him, “Okay then. I want you to tell him ‘I love you’ every day.” He said, “Usually I leave that to the wife, but I can do that.” Second, I said, “Everyday, I want you to touch your son in a kind and loving way.” He asked, “You mean like give him a hug?” I said, “that would be great” and he responded, “Usually I leave that to the wife too, but I’ll give it a shot.” Third, I said, “Once a week, you should do something fun with your son, but it has to be something that he thinks is fun.” He said back: “That’s no problem. We both like to go four-wheeling, so we’ll do that.”

And they left my office for an hour-long of what I imagine was a silent trip home.

The next afternoon, I got a call from the mom. She was ecstatic. She said, “I don’t know what you did or what you said, but they’re talking again.” And then she added, “This morning, when they were in the kitchen, I was in the other room and I thought I heard them hug and when I saw my son walking down the driveway to head to school, there were tears running down his cheeks.”

This was obviously a mom who was listening and watching very closely.

Things got much better for the 15-year-old after that. He didn’t get straight As, but he stopped getting straight Fs. And I learned two things: First, I learned just how much that boy needed to get reconnected with his father. And second, I learned that sometimes, no matter how gruff parents may seem, what they need is some clear and straightforward advice about how to reconnect with their son or daughter.

My final thoughts about this topic are very simple. I hope you’re inspired enough to acquire the knowledge and skills it takes to work effectively with parents. I know their children will deeply appreciate it.

Thanks for listening.

The book upon which the talk is based is available here on Amazon: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_9?s=books&ie=UTF8&qid=1402106002&sr=1-9 . . . and here on Wiley: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118012968.html

Tough Kids, Cool Counseling PowerPoints from SDMHCA May 1 Workshop

Attached to this post are the handouts from the May 1 “Tough Kids, Cool Counseling” workshop in Spearfish, South Dakota.

It was a great day with about 85 wonderful, amazing, and exceptionally nice school and mental health counselors from throughout South Dakota.

This is the powerpoint:

SDMHCA Workshop 14 Part No Cartoons

And this is the supplementary handout:

SDMHCA TKCC Part II Supplement

I hope this information is helpful!

John SF