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Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Multicultural, Therapy with Adolescents

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

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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.

Counseling and Psychotherapy Theory and Practice

Supplementary Counseling and Psychotherapy Theories Readings

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Over the past four years I’ve written over 40 blog posts linked to teaching and learning the theory and practice of counseling and psychotherapy. While procrastinating on another project, I decided to organize these blog posts by topic. If you follow the links below, they’ll take you to blog posts relevant to specific theories. Included in some of these are a few links to short (and free) theories-based video examples. If you teach a theories course, you could select some of these links to assign students outside readings or you could peruse them yourself to stimulate a few lecture ideas.

Please note that if you use our Counseling and Psychotherapy Theories in Context and Practice textbook, there’s a bit of redundancy with the textbook’s content. However, if you don’t use the text, the material will be new to you and your students.

Chapter 1 – Opening and Overview

A Plan for Maximizing Positive Counseling and Psychotherapy Outcomes: https://johnsommersflanagan.com/2014/09/07/a-plan-for-maximizing-positive-counseling-and-psychotherapy-outcomes/

Teaching Counseling and Psychotherapy Theories: Reflections on Week 1: https://johnsommersflanagan.com/2012/08/29/teaching-counseling-and-psychotherapy-theories-reflections-on-week-1/

Reformulating Clinical Depression: The Social-Psycho-Bio Model: https://johnsommersflanagan.com/2013/09/03/reformulating-clinical-depression-the-social-psycho-bio-model/

Chapter 2 – Psychoanalytic Approaches

Attachment-Informed Psychotherapy: https://johnsommersflanagan.com/2015/08/12/attachment-informed-psychotherapy/

Chapter 3 – Adlerian Approaches: Individual Psychology

The Three-Step Emotional Change Trick: https://johnsommersflanagan.com/2012/09/23/the-three-step-emotional-change-trick/

A Parenting Homework Assignment on Natural and Logical Consequences: https://johnsommersflanagan.com/2011/11/30/a-parenting-homework-assignment-on-natural-and-logical-consequences/

More Than Praise — Other Ways Parents Can Be Positive With Their Children: https://johnsommersflanagan.com/2012/08/16/more-than-praise-other-ways-parents-can-be-positive-with-their-children/

Chapter 4 – Existential Approaches

Reflections on Listening to Irvin Yalom at the ACA Conference: https://johnsommersflanagan.com/2012/03/25/reflections-on-listening-to-irvin-yalom-at-the-aca-conference/

A Short Existential Case Example from Counseling and Psychotherapy Theories . . .: https://johnsommersflanagan.com/2015/08/25/a-short-existential-case-example-from-counseling-and-psychotherapy-theories/

Chapter 5 – Person-Centered Approaches

Reflections on Magic: https://johnsommersflanagan.com/2011/11/28/reflections-on-magic/

Listening as Meditation on Psychotherapy.net: https://johnsommersflanagan.com/2014/02/25/listening-as-meditation-on-psychotherapy-net/

An Interview with Natalie Rogers (Daughter of Carl Rogers) about Person-Centered Therapy: https://johnsommersflanagan.com/2015/08/04/an-interview-with-natalie-rogers-daughter-of-carl-rogers-about-person-centered-therapy/

Why Therapists Should Never Say, “I know how you feel”: https://johnsommersflanagan.com/2013/05/30/why-therapists-should-never-say-i-know-how-you-feel/

Carl Rogers and Brain-Science do an Empathy Smackdown in Chapter 3: https://johnsommersflanagan.com/2015/07/09/carl-rogers-and-brain-science-do-an-empathy-smackdown-in-chapter-3/

Chapter 6 – Gestalt Approaches

Go Go Gestalt: The Theories Video Shoot, Part I: https://johnsommersflanagan.com/2012/04/24/go-go-gestalt-the-theories-video-shoot-part-i-2/

Chapter 7 – Behavioral Approaches

A Black Friday Tribute to Mary Cover Jones and her Evidence-Based Cookies: https://johnsommersflanagan.com/2011/11/25/a-black-friday-tribute-to-mary-cover-jones-and-her-evidence-based-cookies/

Behavioral Activation Therapy: Let’s Just Skip the Cognitions: https://johnsommersflanagan.com/2014/06/30/behavioral-activation-therapy-lets-just-skip-the-cognitions/

Imaginal or In Vivo Exposure and Desensitization: https://johnsommersflanagan.com/2012/05/19/imaginal-or-in-vivo-exposure-and-desensitization-2/

A New Look at Time-Out for Kids and Parents: https://johnsommersflanagan.com/2012/08/04/a-new-look-at-time-out-for-kids-and-parents/

Information on Using Time-Out — Part II: https://johnsommersflanagan.com/2012/08/05/information-on-using-time-out-part-ii/

Talking with Parents about Positive Reinforcement: https://johnsommersflanagan.com/2014/09/06/talking-with-parents-about-positive-reinforcement/

Backward Behavior Modification: https://johnsommersflanagan.com/2012/12/02/backward-behavior-modification/

Chapter 8 – Cognitive-Behavioral Approaches

Positive Thinking is Not (Necessarily) Rational Thinking: https://johnsommersflanagan.com/2011/12/06/positive-thinking-is-not-necessarily-rational-thinking/

How to Use the Six Column CBT Technique: https://johnsommersflanagan.com/2014/02/18/how-to-use-the-six-column-cbt-technique/

A Quick Look at the Collaborative Cognitive Therapy Process: https://johnsommersflanagan.com/2012/09/30/a-quick-look-at-the-collaborative-cognitive-therapy-process/

Tomorrow’s Election and Confirmation Bias: https://johnsommersflanagan.com/2012/11/05/tomorrows-election-and-confirmation-bias/

Confirmation Bias on My Way to Spearfish, South Dakota: https://johnsommersflanagan.com/2014/04/30/confirmation-bias-on-my-way-to-spearfish-south-dakota/

Chapter 9 – Choice Theory and Reality Therapy

The Seven Magic Words for Parents: https://johnsommersflanagan.com/2012/12/23/the-seven-magic-words-for-parents/

Give Information and then Back-Off: A Choice Theory Parenting Assignment: https://johnsommersflanagan.com/2012/07/09/give-information-and-then-back-off-a-choice-theory-parenting-assignment/

How Parents Can Use Problem-Solving Power: https://johnsommersflanagan.com/2012/10/23/how-parents-can-use-problem-solving-power/

Chapter 10 – Feminist Approaches

Opening Thoughts on Feminism: https://johnsommersflanagan.com/2012/04/03/opening-thoughts-on-feminism-3/

The Girl Code by Ashley Marallo: https://johnsommersflanagan.com/2012/12/03/the-girl-code-by-ashley-marallo/

A Guest Essay on the Girl Code and Feminism: https://johnsommersflanagan.com/2014/12/07/a-guest-essay-on-the-girl-code-and-feminism/

Feminist Culture in Music: https://johnsommersflanagan.com/2013/11/18/feminist-culture-in-music/

Chapter 11 – Constructive (Solution-Based and Narrative) Approaches

Is Solution-Focused Therapy as Powerfully Effective as Solution-Focused Therapists Would Have Us Believe?: https://johnsommersflanagan.com/2012/07/01/is-solution-focused-therapy-as-powerfully-effective-as-solution-focused-therapists-would-have-us-believe-2/

Secrets of the Miracle Question: https://johnsommersflanagan.com/2015/03/04/secrets-of-the-miracle-question/

The Love Reframe: https://johnsommersflanagan.com/2013/04/07/the-love-reframe/

Chapter 12 – Family Systems Approaches

None posted on this topic. Obviously, I need help here.

Chapter 13 – Multicultural Approaches

Four Good Ideas about Multicultural Counseling and Psychotherapy—In Honor of Martin Luther King, Jr.: https://johnsommersflanagan.com/2012/01/16/four-good-ideas-about-multicultural-counseling-and-psychotherapy-in-honor-of-martin-luther-king-jr/

Good Ideas about Multicultural Counseling and Psychotherapy – Part II: https://johnsommersflanagan.com/2012/01/22/good-ideas-about-multicultural-counseling-and-psychotherapy-part-ii/

Cultural Adaptations in the DSM-5: Insert Foot in Mouth Here: https://johnsommersflanagan.com/2014/07/08/cultural-adaptations-in-the-dsm-5-insert-foot-in-mouth-here/

Psychic Communications . . . and Cultural Differences in Mental Status: https://johnsommersflanagan.com/2013/01/02/psychic-communications-and-cultural-differences-in-mental-status/

A White Male Psychologist Reflects on White Privilege: https://johnsommersflanagan.com/2012/09/14/a-white-male-psychologist-reflects-on-white-privilege/

Chapter 14 – Integrative Approaches

None on this chapter either.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Ethics

A Summary of the American Psychological Association’s Record Keeping Guidelines

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The American Psychological Association (APA) has an online guide to record keeping for psychologists. Of the different mental health disciplines, the APA’s guidelines are the most extensive. For the full guide (and tons of fun), go to: http://www.apa.org/practice/guidelines/record-keeping.aspx. A brief summary of the guide follows.

As an introduction, the APA emphasizes that clinical records are beneficial for clients and practitioners. When done well, clinical records can:

1. Document that planning has occurred
2. Guide treatment services.
3. Allow providers to review and monitor their work.
4. Enhance continuity when there are treatment breaks or referrals to other providers.
5. Protect clients and providers during legal or ethical proceedings.
6. Fulfill insurance or third-party reimbursement requirements.

The APA’s document is a guide and not a mandate. It’s designed as aspirational. APA also notes that there’s no significant empirical research foundation upon which their guidelines are based. Instead, the guidelines are broadly based on APA policy, professional consensus, and other sources of ethics and legal information.

The following list paraphrases and summarizes APA’s 13 guidelines. There’s always the possibility that our list and descriptions include minor mistranslations. Consequently, please see the full document for comprehensive coverage of this important content.

1. Responsibility: Practitioners are responsible for the development and maintenance of their clinical records. This includes training staff in the appropriate confidential handling of client records.

2. Record Content: Records include information about the nature, delivery, treatment progress and outcomes, and fees. Information included is directly relevant to the clinical purpose of client contacts. Although detail is important, the following factors guide the level of details included in individual client case files:

a. Clients’ wishes
b. Disaster or emergency settings
c. Ethical or legal limitations (e.g., HIV testing results)
d. Contracts with third party payers
e. The APA guide includes extensive information regarding what content may or may not be appropriate.

3. Confidentiality: Maintenance of confidentiality is essential. In situations where who has access to records may be unclear (e.g., child custody conflicts), the provider seeks pertinent legal information to guide decision-making.

4. Informed Consent: Practitioners provide clients with information regarding their record keeping procedures, including limits to confidentiality.

5. Records Maintenance: Records are organized to comply with federal law (HIPAA) and accuracy is maintained.

6. Records Security: Records are kept safe from physical damage. Access to records is controlled via a variety of methods, including locked cabinets, locked storage rooms, passwords, data encryption, etc.).

7. Records Retention: Records are retained for a time period consistent with legal requirements. The general guide is seven years after service ended for adults and three years after a minor reaches age 18 (whichever is later).

8. Records Context: Because client symptoms or condition can vary with situational contexts, providers frame the content of client records within the appropriate historical context.

9. Electronic Records: Electronic records use and storage presents ongoing challenges. The best guidance is for practitioners to follow the HIPAA Security Rule, conduct a security analysis, and consistently upgrade policies and practices to keep up with changes in technology.

10. Records within Agencies: Practitioners must balance their professional ethical requirements and agency policy. The APA identifies three main areas: (a) conflicts between the agency and other requirements, (b) records ownership, and (c) records access.

11. Multiple Client Records: When providing couple, family, or group services, records management may become complex. You can consider either creating separate records for all clients or to identify a primary client and keep records for that person.

12. Financial Records: The nature of the fee agreement (including bartering agreements) as well as adjustments to account balances should be specified. Financial records include essential information such as procedure codes, treatment duration, fees paid, fee agreements, dates of service, etc.

13. Records Disposition: In the case of unexpected events, there may be a need for records transfer or disposal. This implies a need for a records transfer and disposal policy, including information on how current and former clients will be informed if the policy needs to be enacted.

The APA guide is a comprehensive document that can help all practicing clinicians maintain high ethical standards with respect to documentation.

Counseling and Psychotherapy Theory and Practice

A Short Existential Case Example from Counseling and Psychotherapy Theories . . .

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Each chapter in Counseling and Psychotherapy Theories in Context and Practice includes at least two case vignettes. These vignettes are brief, but designed to articulate how clinicians can use specific theories to formulate cases and engage in therapeutic interactions. The following case is excerpted from the Existential Theory and Therapy chapter.

This post is part of a series of free posts available to professors and students in counseling and psychology who are teaching and learning about theories of counseling and psychotherapy. It, as well as the recommended video clip at the end, can be used for discussion purposes and/or to supplement course content.

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Vignette II: Using Confrontation and Visualization to Increase Personal Responsibility and Explore Deeper Feelings

In this case, a Native American counselor-in-training is working with an 18-year-old Latina female. The client has agreed to attend counseling to work on her anger and disruptive behaviors within a residential vocational training setting. Her behaviors are progressively costing her freedom at the residential setting and contributing to the possibility of her being sent home. The client says she would like to stay in the program and complete her training, but her behaviors seem to say otherwise.

Client: Yeah, I got in trouble again yesterday. I was just walking on the grass and some “ho” told me to get on the sidewalk so I flipped her off and staff saw. So I got a ticket. That’s so bogus.

Counselor: You sound like you’re not happy about getting in trouble, but you also think the ticket was stupid.

Client: It was stupid. I was just being who I am. All the women in my family are like this. We just don’t take shit.

Counselor: We’ve talked about this before. You just don’t take shit.

Client: Right.

Counselor: Can I be straight with you right now? Can I give you a little shit?

Client: Yeah, I guess. In here it’s different.

Counselor: On the one hand you tell me and everybody that you want to stay here and graduate. On the other hand, you’re not even willing to follow the rules and walk on the sidewalk instead of the grass. What do you make of that?

Client: Like I’ve been saying, I do my own thing and don’t follow anyone’s orders.

Counselor: But you want to finish your vocational training. What is it for you to walk on the sidewalk? That’s not taking any shit. All you’re doing is giving yourself trouble.

Client: I know I get myself trouble. That’s why I need help. I do want to stay here.

Counselor: What would it be like for you then . . . to just walk on the sidewalk and follow the rules?

Client: That’s weak brown-nosing bullshit.

Counselor: Then will you explore that with me? Are you strong enough to look very hard right now with me at what this being weak shit is all about?

Client: Yeah. I’m strong enough. What do you want me to do?

Counselor: Okay then. Let’s really get serious about this. Relax in your chair and imagine yourself walking on the grass and someone asks you to get on the sidewalk and then you just see yourself smiling and saying, “Oh yeah, sure.” And then you see yourself apologize. You say, “Sorry about that. My bad. You’re right. Thanks.” What does that bring up for you.

Client: Goddamn it! It just makes me feel like shit. Like I’m f-ing weak. I hate that.

In this counseling scenario the client is conceptualized as using expansive and angry behaviors to compensate for inner feelings of weakness and vulnerability. The counselor uses the client’s language to gently confront the discrepancy between what the client wants and her behaviors. As you can see from the preceding dialogue, this confrontation (and the counselor’s use of an interpersonal challenge) gets the client to look seriously at what her discrepant behavior is all about. This cooperation wouldn’t be possible without the earlier development of a therapy alliance . . . an alliance that seemed deepened by the fact that the client saw the counselor as another Brown Woman. After the confrontation and cooperation, the counselor shifts into a visualization activity designed to focus and vivify the client’s feelings. This process enabled the young Latina woman to begin understanding in greater depth why cooperating with rules triggered intense feelings of weakness. In addition, the client was able to begin articulating the meaning of feeling “weak” and how that meaning permeated and impacted her life.

To check out a 4+ minute existential counseling video clip go to: https://www.youtube.com/watch?v=jiirtIKcIeM

This clip is taken from our Counseling and Psychotherapy Theories 2 DVD set. The 2 DVD set is available through Psychotherapy.net: http://www.psychotherapy.net/video/counseling-psychotherapy-theories and Amazon: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1118402537/ref=asap_bc?ie=UTF8

Counseling and Psychotherapy Theory and Practice

Attachment-Informed Psychotherapy

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In the past decade or so I’ve been fascinated over the immense growth in popularity of all things “attachment.” Don’t get me wrong, I believe attachment concepts are robust, interesting, and sometimes useful. I guess I’m not on the attachment bandwagon . . . but I’m not altogether off the bandwagon either.

Here’s an excerpt from our Counseling and Psychotherapy Theories text on Attachment-Informed Psychotherapy. I wonder, before you read this do you know the MAIN difference between attachment-informed psychotherapy and psychoanalytic psychotherapy? I ask this because mostly psychoanalytic psychotherapy is in disfavor, but attachment approaches are all the rage. Do you know the difference?

Attachment-Informed Psychotherapy

Attachment, both as a model for healthy child development and as a template for understanding human behavior is immensely popular within the United States (Cassidy & Shaver, 2008; Wallin, 2007). This is especially ironic because attachment theory’s rise to glory parallels decreasing interest in psychoanalytic models. If you were to ask a sample of mental health professionals their thoughts on attachment theory, you’d elicit primarily positive responses—despite the fact that attachment theory is a psychoanalytically oriented approach.

John Bowlby, who was raised primarily by a nanny and sent to boarding school at age seven, began writing about the importance of parent-child interactions in the 1950s. He was a psychoanalyst. Similar to other neo-Freudians, Bowlby’s thinking deviated from Freud’s. Instead of focusing on infant or child parental fantasies, Bowlby emphasized real and observable interactions between parent and child. He believed actual caretaker-infant interactions were foundational to personality formation (aka the internal working model).

In 1970, Mary Ainsworth, a student of Bowlby’s and scholar in her own right, published a study focusing on children’s attachment styles using a research paradigm called the strange situation (Ainsworth & Bell, 1970). Ainsworth brought individual mother-child (6 to 18 months) pairs into her lab and observed them in a series of seven 3-minute episodes or interactions.

1. Parent and infant spending time alone.
2. A stranger joins parent and infant.
3. The parent leaves infant and stranger alone.
4. Parent returns and stranger leaves.
5. Parent leaves; infant left completely alone.
6. Stranger returns.
7. Parent returns and stranger leaves.

During this event sequence, Ainsworth observed the infant’s:

  • Exploration behavior.
  • Behavioral reaction to being separated from parent.
  • Behavioral reaction to the stranger.
  • Behavior when reunited with parent.

Based on this experimental paradigm, Ainsworth identified three primary attachment styles. These styles included:

1. Secure attachment.
2. Anxious-resistant insecure attachment.
3. Anxious-avoidant insecure attachment.

In 1986, Ainsworth’s student and colleague Mary Main (1986, 1990), identified a fourth attachment style labeled, disorganized/disoriented attachment.

Many contemporary therapists view attachment theory in general, and Ainsworth and Main’s attachment style formulations in particular, as having powerful implications for human relationships and the therapy process (Eagle, 2003; Wallin, 2007). For example, one of the most popular approaches to couple counseling relies heavily on attachment theory principles (Johnson, 2010). In addition, attachment theory has profoundly influenced child development and parent training programs (J. Sommers-Flanagan & R. Sommers-Flanagan, 2011).

At its core, attachment theory involves an effort to understand how early child-caretaker interactions have been internalized and subsequently serve as a model for interpersonal relationships. This is, of course, the internal working model—with an emphasis on how real (and not fantasized) early relationships have become a guide or template for all later relationships. Byrd, Patterson, and Turchik (2010) describe how attachment theory can help with selecting appropriate and effective interventions:

Therapists may be better able to select effective interventions by taking the client’s attachment pattern into consideration. For instance, a client who is comfortable with closeness may be able to make good use of the therapeutic relationship to correct dysfunctions in his or her working models of self and others. On the other hand, a client who is not comfortable with closeness may find it difficult to change internal working models through the therapeutic relationship. Finally, knowing that a client is not comfortable with closeness would allow the therapist to anticipate a relatively impoverished alliance, and therefore avoid interventions such as insight oriented or object relations therapies that rely heavily on the alliance. (p. 635)

As an internal working model, attachment theory also has implications for how therapists handle within-session interpersonal process. Later in this chapter we provide an attachment-informed psychoanalytic case example (see the Treatment Planning section).

It should be emphasized that many criticisms of attachment theory exist. Some critiques have similarities to criticisms of psychoanalytic theory. Perhaps the greatest criticism is the tendency for individuals to take the Mary Ainsworth’s 21 minutes of behavioral observations with one primary caregiver and generalize it to the entire global population. In this sense, the theory is not especially multiculturally sensitive. It seems obvious that there are many divergent ways to raise children and not all cultures subscribe to the “American” overemphasis and perhaps preoccupation with the infant’s relationship with a single caregiver (usually the mother).

Although scientific critiques have sought to reign in attachment theory as it has galloped its way into pop psychology and the media (Rutter, 1995), its popularity continues to escalate and the consequences seem to magnify the importance of an overly dramatized dance of love between a child and his or her mother. In the following excerpt from A general theory of love, you can see the language is absolute and, interestingly, rather sexist—in that children are typically portrayed as male and parents as female.

One of a parent’s most important jobs is to remain in tune with her child, because she will focus the eyes he turns toward inner and outer worlds. He faithfully receives whatever deficiencies her own vision contains. A parent who is a poor resonator cannot impart clarity. Her inexactness smears his developing precision in reading the emotional world. If she does not or cannot teach him, in adult-hood he will be unable to sense the inner states of others or himself. Deprived of the limbic compass that orients a person to his internal landscape, he will slip through his life without understanding it. (Lewis, Amini, & Lannon, 2001, p. 156)

Take a moment to imagine how Karen Horney or Mary Ainsworth might respond to this overgeneralization of attachment concepts and blaming of mothers for their children’s emotional deficiencies.

John and Nora

Counseling and Psychotherapy Theory and Practice

An Interview with Natalie Rogers (Daughter of Carl Rogers) about Person-Centered Therapy

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Of all the counseling and psychotherapy approaches out there, person-centered therapy might be the most quickly dismissed of them all. I’ve had therapists watch or listen to a PCT demonstration and then make dismissive comments like: “Oh yeah. That was just basic listening skills. I know all about that.”

It’s usually hard for me to figure out how to best respond to that sort of statement. What makes it hard to take is that typically, when someone says something like, “I already know all that Rogerian stuff,” it’s a surefire sign that they really don’t get person-centered therapy.

Although this is mostly just my opinion, it’s also the opinion of Natalie Rogers (daughter of Carl Rogers, the person who originally developed person-centered therapy). The following is an edited excerpt of two telephone interviews I did with her way back in 2003. This excerpt is included in our theories textbook: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/0470617934/ref=cm_cr_pr_product_top?ie=UTF8

Additional interview material is in an article published in the Journal of Counseling and Development in 2007: http://onlinelibrary.wiley.com/doi/10.1002/j.1556-6678.2007.tb00454.x/abstract

And even more interview material is resting on the hard-drive of my computer.

Other fun and interesting content about person-centered therapy is in our Student Guide: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/0470904372/ref=sr_1_fkmr1_1?s=books&ie=UTF8&qid=1438700878&sr=1-1-fkmr1&keywords=sommers-flanagan+student+guide

Here’s what Natalie had to say about the status of Person-Centered Therapy in the U.S.

Why Is the Person-Centered Approach Undervalued in the United States?

In the following excerpt from two telephone interviews, Natalie Rogers discusses why person-centered approaches tend to be undervalued or overlooked in the United States.

John Sommers-Flanagan (JSF): Other than the managed-care focus and an emphasis on quick fixes, can you think of any reasons why more American therapists aren’t practicing PCT?

Natalie Rogers (NR): That’s a good question. Most psychology students I know only get a chapter or two in the academic world, and they don’t really understand in any depth what the person-centered approach is about. And, most importantly, I think they haven’t experienced it. They’ve read [about] it and they’ve talked about it and they’ve analyzed it, but my own belief is that it really takes in-depth experiencing of the client-centered approach to know the healing power of empathy and congruence and unconditional positive regard.

JSF: So it’s almost like students get more of an intellectual understanding, but you’re just not seeing them get the experiential part.

NR: Even the intellectual understanding is very superficial, because they read maybe a chapter and watch the old Gloria film (Rogers, 1965). The fact that there have been 16 books written on client-centered therapy and a lot of other books now that Carl’s passed away and the research that he did is so profound . . . the in-depth research on what actually helps clients go deeper into their feelings and thoughts.

JSF: Right.

NR: You know, [how therapists can help clients go deeper into their feelings and thoughts] is hardly ever mentioned in academia as far as I know.

JSF: And what I remember from our last conversation was that you said you thought it didn’t happen in the U.S. at all and maybe a little bit in Europe?

NR: I think it does happen a lot more in Europe, and most particularly in the United Kingdom, Scotland and England. They have really excellent training programs in the client-centered approach, and the books that are coming out are coming out from there. You know in Germany they have a several-year, very extensive training program that’s also linked in, I believe, to becoming accredited or licensed as a therapist. Things are going that particular route in Europe, but none of that is here in the States.

JSF: That seems to reflect our own emphasis on the surface or the quick fix as well in that people just really haven’t gone deeper and experienced the power of PCT.

NR: Right. And then again I think the other point is that the ego needs of the therapists [appear] to be strong here. Therapists in this country seem to need to have the attitude that “I have the answers” or at least that “I know more,” and it’s . . . the old medical model that we still hold onto in this country a lot. The doctor knows what he needs to diagnose and treat, knows what’s wrong and that there are ten steps to fix it.

JSF: Right, which seems to be the opposite of the person-centered therapy of “trust the individual, trust the person.”

NR: Not just seems to be, it is the opposite. So, to actually believe, to have faith in the individual, to have faith that each person has the answers within himself or herself if given the proper conditions, and that’s a big if. That philosophy takes a great deal of humility on the part of the therapist.

JSF: For us to realize that we don’t have all the answers for another person.

NR: Right. I kind of like the gardener metaphor. That I’m the gardener and I help till the soil and I help water the plants and fertilize the plants, and care for them. And I need to understand what the plant needs, what conditions that plant needs for it to actually grow and become its full potential. That’s very different. That’s what I see as one metaphor for being a therapist. I don’t know all the answers, but I’m a person who creates the conditions for the person to grow.

JSF: Kind of the fertile field metaphor. So . . . what would you tell beginning therapists that would help them see the tremendous value of following person-centered principles?

NR: Well, I always ask my students to examine their own beliefs about psychotherapy and about what it is that creates psychological feelings and growth. I think it’s a philosophical, spiritual belief system that we’re looking at. People are using the words “methods” and “techniques,” which always puts me off, because although there certainly are methods that we use, it’s much bigger than that. It’s a belief system about the connection between mind, body, and emotional spirit. And so I ask them what do they believe creates personal growth, and what have they experienced themselves that creates growth, and we get them to think and talk about their religious experiences, their psychotherapy experiences, their experiences in nature, and their experiences in relationships. I think they’re all profound. And then when we focus in on relationships, which is what psychotherapy is about, then I want them to experience . . . from me or my colleagues in hour-long demonstrations what it means to be client-centered. So then they experience it as witnesses and they can experience it as a client.

JSF: So more students need to directly experience, or at least witness, client-centered therapy.

NR: Let me give an example. I was talking to a colleague once who had some of my training and who said that he was now using brief therapy, brief psychotherapy, and I admitted I didn’t really know what that was. We decided that he’d have to give me some ideas on what that’s like. So I listened to him describe the theory and practice for quite a while and questioned him about it. And as he was describing it, I was wondering, how would I feel if I were in the client’s chair and this was what was being done to me. And so then I felt pretty uncomfortable, and thought, “I guess I wouldn’t like it.” So I asked him, “Have you ever been a client in this kind of brief therapy yourself?” And he said “No,” and I thought that was inexcusable. To practice something on somebody else that you haven’t experienced in-depth yourself. I think it is inexcusable. So that illustrates in a kind of negative way the point that I wanted to make. You really need to have in-depth experience of that which you are going to have other people do.

Counseling and Psychotherapy Theory and Practice, Tough Kids Cool Counseling

A Relationally-Oriented Evidence-Based Practice Model for Mental Health Counselors

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This paper is an adapted summary and extension of an article recently published in the Journal of Mental Health Counseling (April, 2015, pp. 95-108). The original article was titled: Evidence-Based Relationship Practice: Enhancing Counselor Competence. This abbreviation and adaptation is primarily designed to summarize the content, but also to focus more directly on the implications of developing an evidence-based model especially for mental health counselors. This paper ends with an “Appendix” outlining specific parameters of an evidence-based mental health counseling model. The Appendix material isn’t in the original article. If you’re a member of the American Mental Health Counseling Association, you can find the original article here: https://amhca.site-ym.com/?JMHCv37n2

Foundations

There are two domains that serve as a foundation for all competent mental health practice. These are:

1. Ethical practice
2. Multicultural sensitivity.

Professional counselors must practice ethically. At minimum, this means abiding by the ACA (2014) and American Mental Health Counselors Association (AMHCA; 2010) ethical codes. Ponton and Duba (2009) referred to this commitment as a covenant professional counselors have with and for their clients.

Traditional theoretical perspectives must be modified or expanded to address cultural diversity (J. Sommers-Flanagan, Hays, Gallardo, Poyralzi, Sue, & Sommers-Flanagan, 2009). Clients should not be expected to adapt to their counselor’s theory; rather, counselors should adapt their theory or approach to fit clients (Gallardo, 2013). Although multicultural competence is an ethical mandate, the need to embrace multicultural awareness, knowledge, and skills is also a practical reality. [The original article lists six evidence-based ways in which mental health counselors can adapt their counseling services to be more multiculturally sensitive.]

Evidence-Based Counselor Competence

Given the nature of professional counseling and counselor identity, it seems obvious that mental health counselors should embrace a model for counseling competence and EBP that emphasizes therapeutic relationships. That is why the model I propose considers both theoretically and empirically supported relationship factors and specific interventions (procedures). . . .

The reality is that relational acts and treatment methods are so closely interwoven that in counseling sometimes it is difficult to discern which is operating at a given moment (Lambert & Ogles, 2014). Consequently, the following Relationship-Oriented Evidence-Based Practice (ROEBP) behavioral descriptions incorporate both relational and technical components. The ROEBP behavior list primarily focuses on evidence-based relationship factors, although these relational factors are nearly always teamed with technical procedures.

Evidence-Based Relationship Factors

Each mental health counselor will inevitably display therapeutic relational factors in unique ways that may be difficult for other practitioners to replicate, because anything relational or interpersonal is alive, automatically unique, and therefore resists sterile descriptive language. Nevertheless, counselors can implement the following core relational attitudes and behaviors in their own unique manner and still adhere to EBP principles.

Congruence and Genuineness

In mental health counseling, the counselor is the instrument through which treatment is provided. This is probably why Rogers’s original core condition of congruence (1957) is still central to counseling efficacy. However, because Natalie Rogers (Sommers-Flanagan, 2007) once told me that she believed very few mental health professionals in the U.S. really understand her father’s work, let me make four brief points about congruence [You can read the original article to get the details on this].

The Working Alliance

In 1979, Bordin described the working alliance as a three-dimensional and pan-theoretical therapeutic factor. The three dimensions were (a) forming an emotional bond; (b) counselor-client goal-consensus or agreement; and (c) task collaboration. Researchers have affirmed that these working alliance dimensions contribute to positive treatment outcomes (Horvath, Re, Flückiger, and Symonds, 2011). [Practical ways in which mental health counselors can apply these three dimensions in their work are described in the article.]

Unconditional Positive Regard or Radical Acceptance

Originally, Rogers (1957) described unconditional positive regard as the counselor “experiencing a warm acceptance of each aspect of the client’s experience” (p. 98). This is, of course, often impossible. Though unconditional positive regard is easy and natural when counselor and client values are aligned, the competent counselor recognizes that there will be many discrepancies, small or large, between what the counselor thinks is right and what the client thinks is right. I recall a Pakistani Muslim supervisee who reported that hearing people talk about being gay or lesbian made her feel physically nauseated. To her credit, she worked through this (over a period of two years) and was able to embrace an accepting attitude. . . .

In addition to Rogers’s work, I’ve found Marsha Linehan’s dialectical behavior therapy concept of radical acceptance (1993) very helpful. As someone who has logged many counseling hours with clients who display challenging behaviors, remembering radical acceptance helps me greet even the most extreme and disagreeable (to me) client statements with a genuine accepting response (usually something like, “Thanks so much for sharing that with me and being so honest about what you think”).

Empathic Understanding

You should already be thoroughly familiar with Rogers’s ideas about empathy and the robust empirical support for empathy as a contributor to positive counseling outcomes. However, one important caveat about empathy is that the personal feelings of counselors and ratings of their own empathy are relatively unimportant. What matters is whether and how much clients experience their counselors as empathic. This is a crucial distinction. It is all too easy for all humans—including counselors—to focus on their side of interpersonal experiences. When it comes to whether empathy is a facilitative therapy condition, it is the client’s judgment of whether the counselor was empathic that predicts positive outcomes. . . .

Rupture and Repair

Getting it wrong is a natural part of life and counseling. There will always be empathic misses, poorly timed disclosures, and intermittent disengagement. These should be viewed as inevitable problems in the working alliance. As in many other areas of life, tension in the counselor-client relationship offers both danger and opportunity.

The danger is that counselors will ignore, overlook, or be unaware of relationship tensions or ruptures, in which case clients will be more likely to drop out of counseling and outcomes will be adversely affected. But the chance to correct our missteps is an unparalleled therapeutic opportunity. It involves the powerful process of self-correction and refocusing on the client and the counselor-client relationship. . . .

Although there are many ways to repair or work through relationship rupture, the original article discusses two overarching approaches.

Managing Countertransference

Thirty years ago Steve de Shazer (1984) not only reported that “resistance” had died as a therapeutic concept, he held a funeral for it in his backyard. Similarly, some counselors and psychotherapists might like to bury the whole idea of countertransference, putting it out of sight and out of mind. However, renaming or ignoring constructs will not make them go away.

Counselors are more effective when they are aware of and deal with their own unresolved emotional and behavioral reactions (Hayes, Gelso, & Hummel, 2011). Personal counseling or psychotherapy, clinical supervision, participation in peer supervision groups—such practices can help counselors become aware of and gracefully work through their countertransference reactions.

Implementing In- and Out-of-Session Procedures

Proponents of ESTs and EBP emphasize the importance of employing specific psychological or behavioral procedures with clients. Among the procedures that have empirical support are relaxation, exposure, behavioral activation, and problem-solving (Sommers-Flanagan & Sommers-Flanagan, 2012). In addition, some procedures, such as eye movement desensitization reprocessing (EMDR), have significant empirical support even though it is not clear whether the eye movements themselves or other parts of the tightly controlled EMDR protocol are the “active” ingredients. To be consistent with an evidence-based mental health counseling model, professional counselors should implement empirically supported procedures, but should do so using a collaborative interpersonal process. . . .

Progress Monitoring

Progress monitoring (PM) is a relatively new phenomenon on the evidence-based scene. PM is robustly related to positive outcomes and relatively easy to apply (Meier, 2015). Although not covered by many professional counseling publications, all practicing counselors should integrate some form of PM into their practice.

PM simply means that, formally or informally, counselors consistently check with clients about “how things are going.” Data from empirical studies consistently show, however, that practitioners who use formal progress monitoring rating scales tend to have both more favorable outcomes and fewer negative outcomes or treatment failures (Meier, , 2015). . . .

Concluding Comments

Mental health counselors can and should integrate evidence-based approaches into their practice. Although it might be useful for counselors to seek training in ESTs, embracing and applying evidence-based relationships as a core component of counselor competency is more consistent with professional counselor identity. The purpose of making this distinction and providing the information in this article is to advocate for an alternative evidence-based identity—one that counselors can more wholeheartedly embrace.

In this article I focused on nine relational factors that are empirically linked to positive counseling outcomes. This is only a beginning. Research will continue, and for space reasons I neglected several dimensions of counselor-client relational interactions that are consistent with professional counselor identity. For example, other than a brief discussion of PM, I did not address the potential merits and problems of formal assessment. In the future I would hope for a more distinct assessment model that specifies how counselors interact with clients, emphasizing transparency and collaboration. But that discussion must wait for another day. Until then, I wish you all the best as you incorporate relationally-oriented evidence-based counseling principles into the exceptionally important services you provide.

References are included in the original article

Appendix

[This is added material]

A General Practice Model for Evidence-Based Mental Health Counseling

Different professional groups use different terminology for describing their usual and customary standards for clinical practice. In psychology “empirically-supported” is often, but not always used as a means for identifying an approach that meets scientifically-based standards. Physicians and psychiatrists establish “practice parameters” for treating specific disorders. For example, the American Academy of Child and Adolescent Psychiatry (AACAP) has a Committee on Quality Issues that has generated practice parameters for depressive disorders, obsessive-compulsive disorders, multicultural competency, and many other areas of child and adolescent psychiatric clinical practice.

Given that psychology and medicine have their own language for referring to evidence-based standards, it might be useful for professional counseling to come up with its own terminology. This would be terminology that reflects an emphasis on achieving wellness (rather than the medical model) as well as the relational emphasis consistent with counseling. In the Journal of Mental Health Counseling article I referred to this as: Relationship-Oriented Evidence-Based Practice (ROEBP). This isn’t bad, but I’m guessing someone might be able to do better at capturing counselor identity within an evidence-based practice.

Here’s a first try at outlining an ROEBP for mental health counseling. I recognize that this is mostly a rough outline, but also believe that any practice guidelines that are established for professional mental health counselors should be broad so as to include many different and unique styles that exist among individual counselors.

1. All mental health counselors embrace their professional ethical guidelines and use multicultural sensitivity and appropriate multicultural adaptations when working with individual clients. These foundational competencies and commitments must be present for a professional counselor to claim he or she is practicing evidence-based mental health counseling.

2. Mental health counseling is initiated using a collaborative informed consent process. This process should include both written informed consent (consistent with HIPAA), but also verbal interactions to help make every specific counselors approach and style explicit to prospective clients.

3. When referral information is available to mental health counselors, at least some of this information is shared directly with clients using a positive and strength-based format and interaction.

4. Mental health counselors intentionally employ empirically-supported relationship factors throughout counseling. These include, but may not be limited to:

a. Having an office-setting and interpersonal demeanor that contributes to the development of a positive emotional bond between client and counselor

b. Developing a list of mutually agreed upon problems or goals that constitute the main focus of counseling. This involves a collaborative and empathic process.

c. Working with clients on in-session tasks or procedures that are explicitly linked to the mutually agreed upon counseling problems or goals.

d. Congruence and Genuineness

e. Unconditional Positive Regard or Radical Acceptance

f. Empathic Understanding

g. Managing Ruptures and Engaging in Repair

h. Managing Countertransference

5. Recognizing that clients are sometimes drawn toward and benefit from the application of specific therapeutic procedures, mental health counselors seek permission to use these procedures with clients if they are appropriate for the remediation of a particular problem and/or for client personal growth. The procedures employed should be empirically supported. If they are not empirically-supported (e.g., procedures from energy psychology) clients should be informed that the procedure may be promising, but is not a standard and accepted counseling procedure.

6. Mental health counselors use either a formal or informal progress monitoring procedure to consistently check with clients regarding the client’s perception of counseling progress.

Feel free to email me at john.sf@mso.umt.edu with comments about this article summary and ideas about evidence-based mental health counseling practice.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

What’s the Difference between the Clinical Interview and Full-On Counseling or Psychotherapy?

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I know my obsession with all things clinical interviewing is abnormal. This means I already know that most humans on the planet will have no interest in my hashing out the details and differences between clinical interviewing and psychotherapy. So, why then do I persist on blogging about such things? Well, the answer is simple: Obsessions are thoughts and compulsions are behaviors. Therefore, obsessions and compulsions go together like beans and rice. And so, as George Bush senior might have said, “It wouldn’t be prudent to not follow my clinical interviewing obsessions with a clinical interviewing behavior or two.” Now that I think of it, I’m certain that’s exactly what GWB I would have said, had he been asked about this very important situation.

There is, of course, the other reason. I’m revising (along with Rita) our Clinical Interviewing text to put it into the 6th edition. While doing so I have intermittent inspirations to post some of the new material we’re adding here and there. I think to myself . . . “this is the 6th edition of one of the most profound and exciting textbooks of all time and so I’m sure there might be 6 people out there who are interested in reading about what we’re writing.” Then again, as most of us know from either psychological research or common sense, it’s super-easy for me to fool myself into thinking other people are interested in whatever I’m interested in.

Now, having sufficiently fooled or rationalized or intellectualized or inspired myself . . . I present you with our latest thinking on clinical interviewing vs. counseling and psychotherapy.

Clinical interviewing vs. Counseling and Psychotherapy

Students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question and although it’s tempting to answer flatly, “There’s no difference whatsoever” the question deserves a more nuanced response.

The clinical interview is a remarkably flexible and ubiquitous interpersonal process. It’s designed to simultaneously initiate a therapeutic relationship, gather assessment information, and begin therapy. As such, it’s the entry point for clients (or patients) seeking mental health treatment, case management, or any form of counseling. Depending on setting, clinician discipline, theoretical orientation, and other factors, the clinical interview is also commonly known as the intake interview, the initial interview, the psychiatric interview, the diagnostic interview, the first contact or meeting, or any one of a number of other idiosyncratic and theoretically-driven names (Sommers-Flanagan, 2016, in press).

Although it includes therapeutic dimensions, the clinical interview is viewed primarily as an assessment procedure. This is one reason why clinical interviewing is typically included within the assessment portion of course curricula in counseling, psychology, psychiatry, psychiatric nursing, and social work. However, beginning with Constance Fischer’s work on Individualized Psychological Assessment and continuing with Stephen Finn’s articulation and development of therapeutic assessment, it’s also clear that, when done well, clinical assessment is or can be simultaneously therapeutic.

To make matters more complex, every attitude, technique, and strategy described in this text are also the attitudes, techniques, and strategies used in counseling and psychotherapy. Examples (along with their theoretical orientations) range from projective questions (psychoanalytic), therapeutic questions (solution-focused therapy), unconditional positive regard (person-centered), to psychoeducation (cognitive behavior therapy). Even further, some theoretical orientations ignore or de-emphasize assessment to such an extent that the traditional initial clinical assessment interview is transformed completely into an intervention (think solution-focused or narrative). In other cases, the clinical setting or client problem require that single therapy sessions involve an entire course of counseling or psychotherapy. For example,

“. . . in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish . . . an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.” (Sommers-Flanagan et al., 2015, p. 2)

From this perspective, not only is the clinical interview always the starting point for counseling, psychotherapy, and case management, it also may be the end-point. This is partly because many clients stop treatment after only one therapy session.

There may be other situations where an ordinary therapy session (if there is such a thing) can suddenly transform into a clinical assessment interview. The most common example of this involves suicide assessment interviewing (see Chapter 10). If and when clients begin talking about suicide ideation or exhibiting other suicide risk factors, the usual and customary standard of practice for all mental health and healthcare professionals is to smoothly shift the clinical focus from whatever was happening to a state-of-the-art suicide assessment.

All this leads us to the stunning conclusion: Everything that happens in a full course of counseling or psychotherapy may also occur within the context of a single clinical interview—and vice versa. Although it’s usually the starting point of counseling and psychotherapy, parts of a traditional clinical interview also occur during counseling and psychotherapy, regardless of theoretical orientation. The entire range of attitudes, techniques, and strategies you learn from this text constitute the foundation of skills you’ll need for conducting more advanced and theoretically specific counseling or psychotherapy.

R and J in Field

Boys and Men, Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

Cleavage, Revisited

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It’s revision time for the Clinical Interviewing textbook (the 6th edition is coming). Revision time also means revisiting time. About three years ago I posted a new proposed section for the 5th edition cleverly titled, “Straight Talk about Cleavage.”

This time around I’m posting our slightly revised version of that section. What’s new is that I’m explicitly asking and hoping for your comments and feedback. Please note that this makes me nervous, but we (Rita and I) hope your comments and feedback will help us provide more perspective and depth to our discussion. We don’t want to come across as old fogeys or rabid feminists. Instead, we want to be reasonable, thoughtful, and balanced . . . and so we’re turning to YOU.

The section is below. You can post comments directly here at Word Press for all to see or email me privately at john.sf@mso.umt.edu.

Straight Talk about Cleavage

Although we don’t have any solid scientific data upon which to base this statement, our best guess is that most of the time most people on the planet don’t engage in open conversations about cleavage. Our goal in this section is to break that norm and to encourage you to break it along with us. To start, we should confess that the whole idea of us bringing up this topic (in writing or in person) and saying something like, “Okay, we need to have a serious talk about cleavage” makes us feel terribly old. But we also hope this choice might reflect the wisdom and perspective that comes with aging.

In recent years we’ve noticed a greater tendency for female counseling and psychology students (especially younger females) to dress in ways that might be viewed as somewhat provocative. This includes, but is not limited to, low necklines that show considerable cleavage. Among other issues, cleavage and clothing were discussed in a series of postings on the Counselor Education and Supervision (CES) listserv back in 2012. The CES discussion inspired many of the following statements that follow. Please read these bulleted statements and consider discussing them as an educational activity.

  • Female (and male) students have the right to express themselves via how they dress.
  • Commenting on how women dress and making specific recommendations may be viewed as sexist or inappropriately limiting.
  • It’s true that women should be able to dress any way they want.
  • It’s also true that agencies and institutions have some rights to establish dress codes regarding how their paid employees and volunteers dress.
  • Despite egalitarian and feminist efforts to free women from the shackles of a patriarchal society, how women dress is still interpreted as having certain socially constructed messages that often, but not always, pertain to sex and sexuality.
  • Although efforts to change socially constructed ideas about women dressing “sexy” can include activities like campus “slut-walks,” a counseling or psychotherapy session is probably not the appropriate venue for initiating a discourse on social and feminist change.
  • For better or worse, it’s a fact that both middle-school males and middle-aged men (and many “populations” in between) are likely to be distracted—and their ability to profit from a counseling experience may be compromised—if they have a close up view of their therapist’s breasts.
  • At the very least, we think excessive cleavage (please don’t ask us to define this phrase) is less likely to contribute to positive therapy outcomes and more likely to stimulate sexual fantasies—which we believe is probably contrary to the goals of most therapists.
  • It may be useful to have young women (and men) watch themselves on video from the viewpoint of a client (of either sex) that might feel attracted to them and then discuss how to manage sexual attraction that might occur during therapy.

Obviously, we don’t have perfect or absolute answers to the question of cleavage during a clinical interview. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend you take time to think about this dimension of professional attire and hope you’ll openly discuss cleavage and related issues with fellow students, colleagues, and supervisors.

Counseling and Psychotherapy Theory and Practice, Parenting

Why You Need Special Training to Work Effectively with Parents

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The following case example is excerpted from a chapter I wrote along with two colleagues at the University of Montana, Kirsten W. Murray and Christina G. Yoshimura. This chapter is titled, “Filial Play Therapy and Other Strategies for Working with Parents.” It’s published as Chapter 15 in Foundations of Couples, Marriage, and Family Counseling.

The first 750 words follow.

Parents constitute a complex and challenging population. When parents come to counseling or psychotherapy, they bring unique problems that can test the competence of even the most well-seasoned helping professionals (Holcomb-McCoy & Bryan, 2010; Slagt, Deković, de Haan, van den Akker, Alithe, & Prinzie, 2012). The nature, range, scope, and intensity of parenting problems are immense.

The following case example illustrates the complexity inherent in counseling parents:

Casey and Pat arrive in your office with the intent to discuss concerns about their 6-year-old daughter, Hazel. Initially, they describe their worries about a small behavioral or motor tic that Hazel has developed over the past year. Repeatedly throughout the day and particularly during novel social situations, Hazel cocks her head to the side, rolls her eyes backward, and then brings the knuckle of her right hand upward to her nose. She then presses her knuckle into the side of her nose while scrunching up her face. When Casey or Pat ask her about the purpose of her behavior, she usually reports that her nose “itches on the inside” and that she cannot resist scratching it.

As is often the case with children, Casey and Pat are worried about more than just Hazel’s nose-itching behavior. They’re also worried about how this behavior will affect Hazel’s social development. Hazel will be starting full-day kindergarten in less than a month and Casey and Pat are terrified that other kindergarten students will pick on her. In addition, as you explore their worries about Hazel’s social development, you also discover she’s having severe emotional outbursts (i.e., tantrums) and that neither Casey nor Pat seem to have skills for effectively dealing with their daughter’s anger.

Not long into your session both parents also tell you that their relationship is in crisis. Pat’s anger has been only marginally in control. Their couple conflicts have become more frequent and more intense. Two weeks prior to their counseling appointment they were fighting so intensely that their neighbors called the police. Pat was nearly cited for domestic abuse. Then, Pat quickly escalates in your session, claiming that Casey is too “easy” on Hazel and that Hazel just needs more firm and consistent discipline. Pat gives a short monologue on the effectiveness of spanking. Casey responds with tears, disclosing a personal history of physical abuse and adamant opposition to corporal punishment. Casey emphatically states: “I will not let Pat abuse my daughter.”

Not surprisingly, all this talk about discipline and abuse may raise emotional issues within the helping professional. You may begin to feel like supporting Casey and chastising Pat—at least up until the point that Pat bursts into tears. Pat then begins detailing their financial stressors and the fact that neither of them has had a full-time job over the past year. They’re living in run-down, low-income apartments within a neighborhood that both Pat and Casey find frightening. Eventually, Pat discloses that he has a 13-year-old son from a previous relationship. In an effort to escape the tension between himself and his stepfather, Pat’s teenage son is intermittently showing up at the apartment late at night after a round of drinking with his buddies. When the appointment ends, you end up with more questions than answers.

This case illustrates how working directly with parents is a unique process that requires special knowledge and skills. Pat and Casey present a profoundly complex scenario—even without adding dimensions related to their sexuality or culture. For example, how might Casey and Pat’s parenting and family issues shift if they were a lesbian or gay couple? And how would potential cultural matches or mismatches between the parental dyad and the therapist—or within the parental dyad—affect the therapeutic process and potential outcomes? Obviously, working with Rosa and Miguel or Minkyong and Liang (and all the stereotypes linked to these client names) instead of Casey and Pat might add complexity to the counseling process. Our main point is that you should try not to fool yourself into thinking you can work effectively with parents unless you’ve obtained specific training for working effectively with parents.

This chapter [published in Foundations of Couples, Marriage, and Family Counseling, which is edited by David Capuzzi and Mark Stauffer] describes principles, methods, and techniques for counseling parents. It’s organized into three parts: (1) parenting problems and theoretical models; (2) general knowledge and skills for working directly with parents; and (3) the history, knowledge, and skills associated with Filial Therapy, a specific play therapy approach to working with parents and children.