Category Archives: Counseling and Psychotherapy Theory and Practice

Burning Out, Burning Up, or Just Singed: The Partnership Health Center Powerpoints

California Street FootbridgeThe powerpoints pasted below are from my educational workshop with the staff of Partnership Health Center in Missoula, Montana. In case you didn’t know, PHC provides dental, medical, and counseling services to about 16,000 individuals with limited incomes and who are facing challenging life situations. The people who work at PHC are inspirational. I was fortunate to spend several hours with them this afternoon.

Here’s the ppt: PHC Burnout and SM 2018

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A Bonus Counseling LAB Activity: Person-Centered Problem-Solving

Riverbed and John

After having learned a bit about person-centered theory and therapy and then being exposed to behavior therapy, it makes sense to consider how you can combine the two. For me, the best first step is to integrate your person-centered attitude and skills into a behavioral problem-solving process.

 Person A: As usual, your job is to pretend that you’re a client who’s coming for counseling. You have a minor, but frustrating problem. It helps if the problem is concrete and best if you have a recent experience with it so you can describe it well.

When you sit down with your counselor, take about 5 minutes to describe your problem. Explain how bad it is, how difficult it is to change this problem, and share some of the strategies you’ve tried on your own. As the counselor listens and responds, do your best to respond genuinely back to the counselor and then go with the counseling flow.

Your counselor will engage you in a problem-solving process. Be yourself and participate as you would if you were with a “real” counselor.

Person B: You will be combining your person-centered attitudes and skills with a problem-solving approach. The basic steps to problem-solving [which you should always remember] are as follows:

  1. In collaboration with the client, identify the problem. When you do this, use your listening skills to try to operationalize it in a behaviorally specific way. Remember, you can ask questions, but if/when a person-centered counselor asks questions, the questions are centered on your client’s experiences and emotions. Remember also to avoid asking two questions in a row, because you need to paraphrase before moving to another question.
  2. Brainstorm (generate) a list of possible strategies that your client could use to solve or manage the problem that you’ve collaboratively identified. Remember to: (a) ask your client permission to start making the list, (b) tell your client that you’re only “making a list” to so that both of you can see all of what might be possible, and (c) therefore neither of you can criticize the alternatives/strategies on the list. In fact, you should let your client know that you’d also like to hear some bad ideas or strategies that have been tried, but that didn’t work perfectly.
  3. After you’ve generated 5-10 alternatives, share/show the list to your client and then ask if it would be okay to discuss the pros and cons and likely outcomes linked to each strategy. The purpose here is to collaboratively engage in a reflective process. You’ll want to know about obstacles that might make using some strategies more difficult and potential positive or negative outcomes/side-effects of each strategy. Explore your client’s thoughts, emotions, and reactions to each of the options, using your best listening skills. Behaviorists call this process “means-ends” thinking or “consequential thinking.” Engaging in this process can be naturally behaviorally inhibiting (meaning that it can decrease the chances of an impulsive behavioral response).
  4. Hand the list to your client. Ask something like, “Based on our discussion and on your feelings and thoughts, would you please rank these ideas from 1 to 8, with 1 being your first choice and 8 being your last choice (assuming there were 8 options).
  5. After your client has ranked the ideas, collaboratively make an implementation and evaluation plan. Your client might choose to use 1 or 2 or 3 different strategies. That’s fine. Ask questions like, “How will you remember to try this out?” and “How will you know if your strategy is successful?” You might need to help your client understand that the goal or outcome needs to be within your client’s circle of control. You also might need to provide psychoeducation on solutions often don’t fix things quickly and that it might take weeks to see progress. Let your client know that you’ll be checking in on progress at your next meeting and that although it would be very nice if the strategy has been implemented, it’s also a success to just be thinking about implementing the plan.

Close the session by thanking your client for engaging in this process with you.

A Book Review of Trauma-Sensitive Mindfulness by David A. Treleaven

Ocean ViewThis weekend in Missoula is the Annual Montana Book Festival, so I’ve got books on my mind. In a stroke of good fortune (and thanks to Susan O’Connor and Rita), last night I got to meet David James Duncan, the author of my all-time favorite book, The Brother’s K.  Talking with DJD was ALMOST as fun as reading The Brother’s K, which, if you haven’t read yet, should be on your reading list.

Speaking of Davids and books, several days ago one of our fantastic UM Doc students and I had a book review published in the Journal of Contemporary Psychotherapy. The Doc student’s name is Ariel Goodman (not David), and I have the bragging rights (and honor) of being the co-author of her first (of many to come) publication.

Our review is of Trauma-Sensitive Mindfulness by David A. Treleaven. Ariel and I both liked the book. Although we take him to task a bit for less than perfect scientific rigor, overall the book is very well written and has many excellent ideas about how to safely employ mindfulness with individuals who have previously experienced trauma.

Here’s the review: Goodman-Sommers-Flanagan2018_Article_DavidATreleavenTrauma-Sensitiv

Also, thanks to James Overholser, editor of the Journal of Contemporary Psychotherapy, for giving us the opportunity to do this book review.

We Don’t Always Have to Get Along, But Let’s Strive to NOT Hurt Each Other: Lessons from Alfred Adler

ShoesUnless you’re in my Counseling and Psychotherapy Theories class and studying for your first exam, you probably don’t know much about Alfred Adler. Hence, this post–which happens to simultaneously be part of a study guide for Counseling Theories and part of what we need more of in American discourse.

Adler was a popular psychiatrist in the early 1900s. He was Freud’s contemporary. He wrote about Gemeinschaftsgefühl. But like lots of Adlerian things, Gemeinschaftsgefühl has been overlooked. Adler believed humans were naturally predisposed to work together, cooperatively, in community, with empathy, and positive social feelings. Lydia Sicher, an Adlerian follower, captured his ideas with one of the best professional journal article titles of all time: A Declaration of Interdependence.

Interdependence and Gemeinschaftsgefühl are so natural that, unless we’re broken in some way, we cannot stop ourselves from experiencing empathy; we cannot stop ourselves from helping others in need.

If you know something about Freud, or if you read Chapter 2 of the textbook, you probably recall that Freud was rather competitive. From his conflicts with Janet to his “booting” Adler out of the Psychoanalytic Society, Freud seemed focused on proving himself and holding a dominant position over others. In Freudian psychosexual terms, we might think of this as a fixation at the phallic developmental stage. From an Adlerian perspective, Freud’s behavior represents an excessive striving for superiority. Think about that as you think about contemporary American politics. Might there be an excessive striving for superiority in politics? I often wonder, if you’re already in a position of dominance, why is it necessary to “put down” others as they strive to have their voices heard?

The explanations for this consistent phenomenon across all political parties might be Freudian or they might be Adlerian. Either way, it’s important to learn something about how Adler’s responses to competition and superiority issues were much different than Freud’s. Even as a youth, Adler didn’t obtain gratification from dominating others. Mosak and Maniacci (1999) described a story about what was perhaps Adler’s one and only physical conflict:

Adler became embroiled in a conflict with a classmate, and a fight broke out. Adler struck the boy, and hurt him. He vowed not to fight again (p. 2).

Consider this. It appears Adler won the fight. He hurt the other boy. But instead of obtaining gratification from dominating or hurting someone else and wanting to repeat that behavior, he vowed never to fight again.

I share this story because it captures some of Adler’s theory of individual psychology. Perhaps because he already felt useful and as if he belonged, Adler obtained no additional gratification from having physical power over another. Instead, his aggressive outburst appeared to activate his social interest and compassion. He discovered he did not want to hurt other people. We could all use a little more Adler in our psyches. Not wanting to hurt others would generally be helpful in friendships, romantic relationships, and when conflict occurs. We can always argue and debate over ideas—but how about if we do that with respect and without any intent or motivation to hurt the other person?

In the anecdote about his fight, Adler is clearly not motivated or pulled toward proving his superiority. In another Adler anecdote, his biographer, Phyllis Bottome, described him as “very ordinary.” She wrote:

[He was] a very ordinary 57-year-old man who simply possessed a deep and abiding interest in the lives of ordinary people (Bottome, 1962 #234).

On that note, let’s review the theory and practice of Alfred Adler, an ordinary man who had an interest in ordinary people like you and me.

Theory Review: Dr. John’s Study Tips on Adlerian Theory

Adlerian theory is a little like an iceberg. It’s seems simple and manageable on the surface, but gets more complex as you dive down and try to explore it more completely. As a consequence, I recommend that you stay with the basics; if you decide to go the Adlerian path, there are many ways to explore the theory in greater depth. The following statements about people will help you get in touch with your inner Adlerian—at least for now.

  1. People are unique (idiographic) whole beings (holistic) who act with a sense of purpose (purposeful behavior). This sense of purpose is there whether the person realizes it or not.
  2. Part of an Adlerian therapist’s goals is to help clients have insight or become aware of their purposeful behavior. This insight generates motivation. In some cases clients may not be able to become aware of their deeper behavioral purpose. If so, just becoming aware of the behavior and its negative price can be enough to ignite motivation for change.
  3. Not only is the concept of social interest unique to Adlerian therapy, but the idea that developing social interest, a community feeling or spirit, and having compassion and empathy for others as a therapeutic goal is radical.
  4. Social interest flows from or is related to Adler’s inferiority concept. Think about it this way: We all feel inferior in some ways. But if we focus too much on our own inferiority, it will almost always lead down the dead end of excessive self-interest in compensating for inferiority (e.g., acting superior) or buckling under to our inferiority feelings and complexes (e.g., chronic low self-esteem or depression). This is why focusing on others—and even on their natural inferiority feelings—can help move clients away from the narcissistic or depressive extremes associated with excessive self-interest.
  5. Everyone’s overall way of being is highly subjective. Our style of life (or cognitive schema about self, others, and the world) is created or constructed from our subjective experiences. If you have siblings or caretakers and you sit down and talk about shared memories, you may discover you hold differing perceptions of what happened—even though you were all there together!! This is an example of the subjectivity filter that affects our individual experiences (phenomenology) and that then contributes or feeds back into our style of life.
  6. Therapy is all about fixing our internal, cognitive map (style of life) so it works as perfectly as possible. This requires feedback, awareness, and motivation to fix the distortions in our subjective internal map. The therapist’s role is to guide or assist clients in looking at these distortions (basic mistakes) and making appropriate changes. Therapists explicitly encourage (or give courage to) clients so that clients can feel encouraged (and have courage).
  7. When clients are encouraged and motivated (because they see the maladaptive nature of parts of their lifestyle), they naturally move forward toward a more complete or perfect self that is able to better face and manage the six Adlerian tasks of life.

This is probably enough Adler for now. But if you’re interested in more, you can find it on a new and exciting website called AdlerPedia: https://www.adlerpedia.org/

 

 

 

 

Internship Class Reflections

Evening in M 1

Due to my poor time management skills, I ran out of time for comments during my Tuesday internship class. This error provided a sudden inspiration to continue making comments to my students via email. I asked their permission and they seemed interested. It reminded me of a technique Rita used to use when running groups. Following every group, she would write her own insightful reflective comments and send them out to the group members.

Here’s what I shared with me students . . . with . . . of course . . . all identifying information removed.

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In class I mentioned that I wanted to email you some ideas I didn’t have time to share . . . so here we go.

Based on the small amount of recording we listened to together, it sounded like our rock star counselor-in-training (aka “Rocky”) has established an excellent “relationship” or working alliance with her client. That being the case, many things are possible.

The first thing is what I already mentioned at the very end of class. Using her relational connection as a foundation, Rocky can use any of a number of strategies to open up a discussion about her changing her approach to less listening and more engagement. This doesn’t mean I think Rocky “should” be more active, but because Rocky feels it to some degree and brought it up with us, it’s a signal to me that it might be an issue worth exploring. Here’s an example:

“I’ve been thinking about how I act during our counseling sessions. Sometimes I notice myself sitting back and listening as you tell me a story about your life. I think the stories are important, so I mostly just stay quiet and listen. But I’m also wondering if, because the stories are important parts of your life, if maybe I should be more active and engaged with you as you share your stories with me. It might be better for me to ask questions, make comments, or try to identify patterns. If it’s okay with you, I’d like to talk a bit more. Would you be okay with that? If I try it and you don’t like it, we can always switch back.”

This way of bringing up the issue places the focus on Rocky’s behavior and it models how part of counseling involves self-reflection/analysis. It also introduces the idea as an experiment that both Rocky and her client can comment on.

The second issue I wanted to discuss more is the client’s reluctance to “get into her emotions.” Of course, this is a very common reluctance. If we look at it through a motivational interviewing lens, it’s very possible for her to be ambivalent about getting emotional. Part of her can see the value and part of her is afraid or reluctant.

One possible strategy, among many, is for Rocky to affirm that it’s okay to avoid talking about emotions (at least for now), but that in the meantime, it might be helpful to explore what makes talking about emotions feel so challenging. The point is to focus on “what gets in the way” of talking about the emotions directly first, and only then, after greater understanding is obtained, possibly move forward and experience the emotions.

Using this strategy, the assumption is that there are negative expectations (cognitions) linked to directly feeling/experiencing emotion. One of the following could be possible: (a) “I’m afraid once I open the emotional box, I won’t be able to stop” (then you explore if this has happened and examples of how she has recovered after being emotional in the past); (b) “I’m worried that you’ll judge me” (then you explore the possibility of that happening; (c) “I feel weak when I get emotional” (this might inspire a discussion about whether facing emotions directly is an example of being weak or being strong, or something else).

These are just some examples of the thoughts/expectations that can interfere with emotional processing. Many other unique scenarios are possible. In my experience, if you use collaborative empiricism to explore negative expectations, sometimes the expectations can be managed . . . and sometimes clients will spontaneously start talking about the benefits of emotional expression.

My last idea is related to a component part of EMDR. When clients have an image or situation linked to a specific trauma, EMDR practitioners employ two questions that are IMHO quite powerful. Here they are, using a made up scenario:

  1. “When you imagine the scene at your mother’s funeral, what negative belief about yourself comes into your mind?”

You might have to repeat that question because it’s complicated. The assumption here is that the trauma memory is linked to a core negative belief about the self.

Then you move to the opposite question:

  1. “When you imagine the scene at your mother’s funeral, what positive belief about yourself would you rather have come into your mind?”

You don’t have to be using EMDR to find your client’s answers to these questions very useful. The first answer is the disturbing or dysregulating belief. It needs desensitizing or disputing or something. The second answer is a new belief about the self that may constitute a major therapeutic goal. It needs supporting; it needs to become a possibility.

So . . . how do you get there? Well, I’d go on, but we need to have something to talk about next week:).

Have a great evening.

John

 

Feeling Anxious? Learn the One and Only Method for Self-Regulation

Back in 1980, one of my supervisors at Woodside Hospital in Vancouver, WA, gave me a big compliment. At the time, I was a recreational therapist in a 22-bed psychiatric hospital. In a letter of recommendation, the supervisor described me as having a special knack for translating complex psychological phenomena into concrete activities from which patients could learn. To be honest, I really had no idea what I was doing.

But I think he was onto something about me and my personality. I like to integrate, summarize, and boil down information into digestible bits. Sometimes I have to get the facts to play Twister to get otherwise incompatible perspectives to fit together. This tendency is probably why I’ve written textbooks on clinical interviewing and counseling theories.

Today, I’m tackling anxiety, anxiety reduction, and self-regulation. This feels more personal than usual, mostly because I’ve been dysregulated, more or less, since November 9, 2016.

After reading and thinking about anxiety and anxiety reduction for 30+ years, I’m strongly leaning toward the position that there’s only one, single, universal method to achieve self-regulation. The method is Mary Cover Jones’s counterconditioning. You probably already know that I think Mary Cover Jones is fabulous.

As a means of exploring this unifying method, I recently did a podcast on it with Sara Polanchek. I’ll write more later, but for now, if you’re interested, check out the podcast. It’s the latest episode (7/19/18 release date). You can listen on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

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

If you do listen, please let me know what you think. That way I can continue with integration and synthesis by incorporating your thoughts into my thoughts. I’ll bet you can find many different ways to communicate with me.

If you don’t listen, no worries, I’ll just keep hanging out here in my personal echo chamber.

The Secret Self-Regulation Cure (Seriously this time)

The Road“I’m in suspense,” Sara said. “I’ve been in suspense since the last time we recorded, because John said he had this big secret and I don’t know what it is.”

Partly Sara was lying. She wasn’t in much suspense, mostly because the “last time we recorded” had been only five minutes earlier. But, as I’m sure you realize, capturing and magnifying in-the-moment excitement is the sort of behavior toward which we Hollywood podcasting stars are inclined.

Sara stayed enthusiastic. When I told her that I thought every self-regulation and anxiety reduction technique on the planet all boiled down to a single method that Mary Cover Jones developed in 1924, she said things like, “That’s exciting!” and “I love Mary Cover Jones.”

[Side note] If you end up needing a podcasting co-host, be sure to find someone like Sara who will express enthusiasm even when you’re talking about boring intellectual stuff. [End of side note.]

Mary Cover Jones was the first researcher to employ counterconditioning with humans (although she rarely gets the credit she deserves—but that’s another story). Counterconditioning involves the pairing a desirable (pleasant or comforting) stimulus with a stimulus that usually causes anxiety or dysregulation. Over time, with repeated pairing, the pleasant feelings linked with the desirable stimulus are substituted for the anxiety response. Eventually, the person who has experienced counterconditioning can more comfortably face the undesirable and previously anxiety-provoking stimulus.

My belief is that counterconditioning is the first, best, and only approach to self-regulation and anxiety reduction. Put another way, I’d say, “If it works for self-regulation, then what you’re doing is counterconditioning—even if you call it something else.”

I know that’s a radical statement. Rather than defend my belief and philosophy, let me move on and describe how you can begin using counterconditioning to make your life better.

Let’s say your goal is for you to experience more calmness and relaxation and less agitation and anxiety. That’s reasonable. According to Herbert Benson of Harvard University, you need four things to elicit the relaxation response.

  1. A quiet place
  2. A comfortable position
  3. A mental device
  4. A passive attitude

Benson was studying meditation way back in the early 1970s. Okay. I know I’m digging up lots of old moldy stuff from the past. But take a deep breath and stay with me.

Let’s say you’re able to find a quiet place and a comfortable position. If you’re a parent, that might be tough. However, even if you find it for 12 minutes as you lie in bed, waiting for sleep, that’s a start. And really, all you need is a start, because once you get going, you don’t really even need the quiet place and comfortable position. On airplanes, I use this all the time and it’s not quiet and I’m not physically comfortable.

The next question that most people ask is: “What’s a mental device?” or, “Is that something I have to strap on my head?”

A mental device is a mental point of focus. In Benson’s time and in transcendental meditation, the popular word for it was “Mantra,” but Benson’s research showed that it can be almost anything. One mental device (that’s actually physical) is deep breathing. Another one is to sit comfortably and to think (or chant) the word OM. Benson also found that simple words, like the numbers “one” or “nine” also were effective. But, as I mentioned on the podcast, you can use other words, as long as they are—or can become—comforting. For example, I know people who use the following words:

  1. I am here
  2. Here I am
  3. Peace
  4. Shalom
  5. Banana

For those of you with religious leanings, you might want to use a specific prayer as your mental device. For those of you who are more visually inclined, you could use a mental image as your mental device. For those of you who are physically-oriented, you could use progressive muscle relaxation or body scanning.

The point is that all you need is a point . . . of focus.

Now comes the hard part. Because we’re all human and therefore, imperfect, no matter how compelling or comforting or soothing your mental device might be, you won’t be able to focus on it perfectly. You will become distracted. At some point (and for me it’s usually very early in the process), you’ll find your mind wandering. Instead of focusing on your prayer, you’ll suddenly realize that you’re thinking about a recent movie you saw or a painful social interaction you had earlier in the day or your mind will drift toward a future social situation that you’re dreading.

What’s the solution to the wandering mind?

Well, one thing that’s not the solution is to try harder.

Instead, what Benson meant by a “passive attitude” is that we need to gently accept our mental wanderings and distractions. More commonly, the words we use for Benson’s passive attitude are “Mindful acceptance.” In other words, we accept in the moment of distraction and every moment of distraction, that we are humans who naturally become distracted. And then, after the noticing and after the acceptance, we bring ourselves back to the moment and to our chosen mental device.

On the podcast, Sara asked, “What if, as I try to focus on my mental device, I notice that all the while I have an inner voice talking to me in the background?”

What an excellent question! The first answer is, of course, mindful acceptance. For example, when you notice the inner voice, you might say to yourself, I notice my mind is chattering at me in the background as I focus on my mental device. Then, without judging yourself, you return to your mental device. A second option is for you to find a more engaging or more soothing mental device. Perhaps, you need two mental devices at once? For example, that might include a soft, silky blanket to touch, along with your “I am here” mantra.

As Mary Cover Jones illustrated over 90 years ago, the counterconditioning process is a powerful tool for anxiety reduction and self-regulation. I happen to think that it’s the only tool for anxiety reduction and self-regulation. Whether you agree with me or not isn’t important; either way, don’t let anything I’ve written here get in the way of you identifying and using your own cherished mental (or physical) device. At first, it might not work. It will never work perfectly. But, like Charles Shulz was thinking when he created Linus’s special blanket, life is way better when you live it with a comforting counterconditioning stimulus.

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For more information about Mary Cover Jones, you can go here: https://johnsommersflanagan.com/2011/11/25/a-black-friday-tribute-to-mary-cover-jones-and-her-evidence-based-cookies/

Or here: https://johnsommersflanagan.com/2017/07/17/brain-science-may-be-shiny-but-exposure-therapy-is-pure-gold/

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As I write this (6/4/18), the podcast isn’t quite up yet . . . but will be soon!

To listen to The Secret Self-Regulation Cure on iTunes, go here: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

To listen to The Secret Self-Regulation Cure on Libsyn, go here: http://practicallyperfectparenting.libsyn.com/

To check out our podcast Facebook page, go here: https://www.facebook.com/PracticallyPerfectParenting/