Category Archives: Counseling and Psychotherapy Theory and Practice

Counseling and Psychotherapy Theory and Practice

Check Out the April 2015 Issue of the Journal of Mental Health Counseling for an Article on Evidence-Based Relationship Practice

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This is an excerpt of the first portion of an article I had the honor to publish in the Journal of Mental Health Counseling. My thanks go to Rich Ponton, the JMHC editor for both his patience and for making this article possible. The first 835 words of the article follow. For the whole thing, you can go to the JMHC website: http://www.amhca.org/?page=jmhc

Competence in mental health counseling is inevitably complex and multidimensional. Ironically, the complexity can become overwhelming when well-intended professionals work together to identify the knowledge and skills counselors need to be considered competent. A good example of this is the standards defined in 2009 by the Council for Accreditation of Counseling and Related Educational Program (CACREP, 2009). To establish competence in mental health counseling, the standards require that counselor training programs integrate into their curricula eight core knowledge-based standards and six specialty standards. The eight core standards are splintered into 67 learning objectives and the six specialty standards into 61 critical knowledge and skill components that must be measured as student learning outcomes (Minton & Gibson, 2012). To further elaborate the complexity, the American Mental Health Counseling Association (AMHCA, 2010) has its own Standards for the Practice of Mental Health Counseling.

The myriad standards mean that counselor educators and counseling students must determine exactly how the 128 CACREP competencies (many of which are clearly unrelated to actually doing counseling) and the AMHCA clinical and training standards together translate into mental health counselor competence. Although meeting this challenge can be intellectually exhilarating, moving from the standards to how mental health counselors should act in the room with clients is far from intuitive.

This article represents an effort to gather evidence-based practice (EBP) principles and describe them in terms of practical behaviors or approaches that contribute to counselor competence and positive client outcomes. Although considering the standards conceptually is necessary and sometimes helpful, the purpose of this article is to present a straightforward EBP model that can be tailored to fit different theoretical orientations and individual counselor styles.

What Is Evidence-Based Mental Health Counseling Practice?
Historically, the counseling profession has not had a strong science or research emphasis (Sexton, 2000; Yates, 2013). In fact, a PsycINFO title search of the top five professional counseling journals revealed only 12 articles over the past 15 years that had “evidence-based” or “empirically-supported” in their titles (the journals were Counselor Education and Supervision, Counseling Outcome Research and Evaluation; Journal of Counseling and Development; Journal of Mental Health Counseling; and Journal of Multicultural Counseling and Development). In a systematic review, Ray and colleagues (2011) reported that only 1.9% of articles in counseling journals are concerned with outcomes research. No wonder, as Yates (2013) wrote in Counseling Outcome Research and Evaluation, “Despite the recommendations for infusing outcome research and evidence-based practices (EBPs) into the counseling profession, there still exists uncertainty and confusion from educators and students about what EBP is” (p. 41).

In some ways it is right and good that professional counselors have a less scientific orientation than related disciplines. After all, mental health counseling evolved, in part, as an alternative to treatments provided by psychologists and psychiatrists (Gladding, 2012). This less rigorously scientific approach may partly explain why the public usually views professional counselors as more “helpful, caring, friendly . . . , and understanding” than psychologists and psychiatrists (Warner & Bradley, 1991, p. 139). The purpose of this article is certainly not to make a case for professional counselors to become more rigidly scientific but rather to help counselors embrace practical and relevant scientific research while maintaining a friendly interpersonal style and a wellness-oriented professional identity (Mellin, Hunt, & Nichols, 2011).

Terminology
Like all words, the terms used to describe evidence-based counseling and psychotherapy are linguistic inventions designed to communicate important information. Unfortunately, evidence-based terminology has by now evolved into what might best be described as Babel-esque. Therefore, before outlining an evidence-based mental health counseling model, I look briefly into the politics, history, and usage of evidence-based terminology.

Evidence-based terminology originated in medicine, spilled over into psychology, and from there made its way to professional counseling, education, social work, prevention, business, and nearly every other corner of the first world. Recently I was at a conference where the keynote speaker described not including purple on Powerpoint slides as a best practice. Although no doubt the speaker’s comments were based on something, I was not convinced that the something had anything to do with scientific research.

In mental health treatment, at least some of the confusion about EBP originated in 1986, when Gerald Klerman, then head of the National Institute for Mental Health (NIMH), remarked in a speech to the Society for Psychotherapy Research (perhaps with irony) that “We must come to view psychotherapy as we do aspirin” (quoted in Beutler, 2009, p. 308). Klerman was promoting the medicalization of psychotherapy as a means to compete for limited health care dollars. He was advocating scientific analysis and application of psychotherapy for specific ailments. The use of aspirin as his medical analogy was ironic because, although the active ingredient in aspirin is well-known (acetyl salicylic acid), until the early 1980s little was known about how and why aspirin worked—and even today there remain mysteries about aspirin’s mechanism of action and range of application. However, like aspirin Klerman’s comments had a specific effect but also triggered gastrointestinal side effects in some professionals .

Bowling

Cool Counseling, Counseling and Psychotherapy Theory and Practice

Secrets of the Miracle Question

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Suicide Risk Factors: Part II

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There are many ways to think about suicide risk factors. In my last post, I focused on demographic and ethnic factors related to death by suicide. In this post, the focus is on the broad category of Mental Disorders and Psychiatric Treatment. The next post will focus on Personal and Social Factors that are linked to suicide.

As you’ll see below, the relationship between mental disorders, psychiatric treatment, and suicide is complex. The following material is adapted from our textbook, Clinical Interviewing and so you can find more information there: http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=asap_B0030LK6NM?ie=UTF8

Mental Disorders and Psychiatric Treatment

In general, psychiatric diagnosis is considered a risk factor for suicide. However, some diagnostic conditions (e.g., bipolar disorder and schizophrenia) have higher suicide rates than others (e.g., specific phobias and oppositional-defiant disorder). Several diagnostic conditions associated with heightened suicide risk are discussed in this section.

Schizophrenia

Schizophrenia is a good example of a mental disorder that has a complex association with increased suicide risk. As you may realize, many individuals diagnosed with schizophrenia are unlikely to attempt suicide or die by suicide. Some individuals with a schizophrenia diagnosis are at higher suicide risk than others.

In 2010, Hor and Taylor conducted a research review of risk factors associated with suicide among individuals with a diagnosis of schizophrenia. They initially identified 1,281 studies, eventually narrowing their focus to 51 with relevant schizophrenia-suicide data. Overall, they reported a lifetime suicide risk of about 5% (Hor & Taylor, 2010). Given that the annual risk in the general population is about 12 in 100,000 and assuming a life expectancy of 70 years the general lifetime risk is likely about 840 in 100,000 or 0.84%. This suggests that suicide risk among individuals diagnosed with schizophrenia is about 6 times greater than suicide risk within the general population.

However, there are unique predictive factors within the general population of individuals diagnosed with schizophrenia that further refine and increase suicide prediction. Hor and Taylor (2010) reported the following more specific suicide risk factors within the general population of individuals with a schizophrenia diagnosis:

  • Age (being younger)
  • Sex (being male)
  • Higher education level
  • Number of prior suicide attempts
  • Depressive symptoms
  • Active hallucinations and delusions
  • Presence of insight into one’s problems
  • Family history of suicide
  • Comorbid substance misuse (p. 81)

If you’re working with a client diagnosed with schizophrenia, the lifetime suicide prevalence for that client is predicted to be higher than in the general population. Presence of any of the preceding factors further increases that risk. This leaves a “highest risk prototype” among clients with schizophrenia as:

A young, male, with higher educational achievement, insight into his problems/diagnosis, a family history of suicide, previous attempts, active hallucinations and delusions, along with depressive symptoms and substance misuse.

Given what’s known about suicide unpredictability, it’s also important to remember that someone who fits the highest risk prototype may not be suicidal, whereas a client with no additional risk factors may be actively suicidal.

Depression

The relationship between depression and suicidal behavior is very well established (Bolton, Pagura, Enns, Grant, & Sareen, 2010; Holikatti & Grover, 2010; Schneider, 2012). Some experts believe depression is always associated with suicide (Westefeld and Furr, 1987). This close association has led to the labeling of depression as a lethal disease (Coppen, 1994).

It’s also clear that not all people with depressive symptoms are suicidal. In fact, it appears that depression by itself is much less of a suicide predictor than depression combined with another disturbing condition or conditions. For example, when depression is comorbid (occurring simultaneously) with anxiety, substance use, post-traumatic stress disorder, and borderline or dependent personality disorder, risk substantially increases. (Bolton et al., 2010). Earlier research also supports this pattern, with suicidality increasing along with additional distressing symptoms or experiences, including:

  • Severe anxiety
  • Panic attacks
  • Severe anhedonia
  • Alcohol abuse
  • Substantially decreased ability to concentrate
  • Global insomnia
  • Repeated deliberate self-harm
  • History of physical/sexual abuse
  • Employment problems
  • Relationship loss
  • Hopelessness (Fawcett, Clark, & Busch, 1993; Marangell et al., 2006; Oquendo et al., 2007)

Given this pattern it seems reasonable to conclude that when clients are experiencing greater depression severity and/or additional distressing symptoms, suicide risk increases. Van Orden and colleagues offered a similar conclusion:

. . . data indicate that depression is likely associated with the development of desire for suicide, whereas other disorders, marked by agitation or impulse control deficits, are associated with increased likelihood of acting on suicidal thoughts. (Van Orden et al., 2010, p. 577)

Bipolar Disorder

Research has repeatedly shown that individuals diagnosed with bipolar disorder at increased risk of suicide. Similar to schizophrenia and depression, there are many specific risk factors that predict increased suicidality among clients with bipolar disorder.

In a large-scale French study, eight risk factors were linked to lifetime suicide attempts (Azorin et al., 2009). These included:

1. Multiple hospitalizations
2. Depressive or mixed polarity of first episode
3. Presence of stressful life events before illness onset
4. Younger age at onset
5. No symptom-free intervals between episodes
6. Female sex
7. Greater number of previous episodes
8. Cyclothymic temperament (p. 115)

These findings are consistent with the research on unipolar depression; it appears that severity of bipolar disorder and accumulation of additional distressing experiences increase suicide risk. Another study identified (a) White race, (b) family suicide history, (c) history of cocaine abuse, and (d) history of benzodiazepine abuse were associated with increased suicide attempts (Cassidy, 2011)

Post-Traumatic Stress

In 2006, renowned psychologist Donald Meichenbaum reflected on his 35-plus years of working with suicidal clients. He wrote:

In reviewing my clinical notes from these several suicidal patients and the consultations that I have conducted over the course of my years of clinical work, the one thing that they all had in common was a history of victimization, including combat exposure (my first clinical case), sexual abuse, and surviving the Holocaust. (Meichenbaum, 2006, p. 334)

Clinical research supports Meichenbaum’s reflections. For example, in a file review of 200 outpatients, child sexual abuse was a better predictor of suicidality than depression (Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). Similarly, data from the National Comorbidity Survey (N = 5,877) showed that women who were sexually abused as children were 2 to 4 times more likely to attempt suicide, and men sexually abused as children were 4 to 11 times more likely to attempt suicide (Molnar, Berkman, & Buka, 2001). Overall, research over the past two decades points to several stress-related experiences as linked to suicide attempts and death by suicide (Wilcox & Fawcett, 2012). These include general trauma, stressful life events, and childhood abuse and neglect. Characteristics of these experiences that are most predictive of suicide are:

  • Assaultive abuse or trauma.
  • Chronicity of stress or trauma.
  • Severity of stress or trauma.
  • Earlier developmental stress or trauma. (Wilcox & Fawcett, 2012)

These particular life experiences appear related to suicidal behavior across a variety of populations—including military personnel, street youth, and female victims of sexual assault (Black, Gallaway, Bell, & Ritchie, 2011; Cox et al., 2011; Hadland et al., 2012; Snarr et al., 2010; Spokas, Wenzel, Stirman, Brown, & Beck, 2009).

Substance Abuse

Research is unequivocal in linking alcohol and drug use to increased suicide risk (Sher, 2006). Suicide risk increases even more substantially when substance abuse is associated with depression, social isolation, and other suicide risk factors.

One way that alcohol and drug use increases suicide risk is by decreasing inhibition. People act more impulsively when in chemically altered states and suicide is usually considered an impulsive act. No matter how much planning has preceded a suicide act, at the moment the pills are taken, the trigger is pulled, or the wrist is slit, some theorists believe that some form of disinhibition or dissociation has probably occurred (Shneidman, 1996). Mixing alcohol and prescription medications can further elevate suicide risk.

Several other specific mental disorders have clear links to death by suicide. These include:

  • Anorexia nervosa
  • Borderline personality disorder
  • Conduct disorder (see Van Orden et al., 2010)

Post-Hospital Discharge

For individuals admitted to hospitals because of a mental disorder, the period immediately following discharge carries increased suicide risk. This is particularly true of individuals who have additional risk factors such as previous suicide attempts, lack of social support, and chronic psychiatric disorders. Overall, suicide ideation and attempts are predictably high. In one study 3.3% completed suicide within 6 months of discharge, whereas 39.4% had self-harm behaviors or suicide attempts (Links et al., 2012). Another study reported “3% of patients categorized as being at high risk can be expected to commit suicide in the year after discharge” (Large, Sharma, Cannon, Ryan, & Nielssen, 2011, p. 619).

Selective Serotonin Reuptake Inhibitors (SSRIs)

Over the past two decades, empirical data linking SSRI medications to suicidal impulses has accumulated to the point that recent administration of SSRI medications should be considered a possible suicide risk factor (Breggin, 2010; Valenstein et al., 2012). This is true despite the fact that some research also shows that SSRI antidepressants reduce suicide rates (Kuba et al., 2011; Leon et al., 2011). Overall, it appears that in a minority of clients (2–5%) SSRI antidepressants may increase agitation in a way that contributes to increased risk for suicidal behaviors (J. Sommers-Flanagan & Campbell, 2009).

In September 2004, an expert panel of the U.S. Food and Drug Administration (FDA) voted 25–0 in support of an SSRI-suicide link. Later, the panel voted 15–8 in favor of a “black box warning” on SSRI medication labels. The warning states:

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

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

There’s no doubt that debate about whether SSRI medications increase suicide risk will continue. In the meantime, prudent practice dictates that mental health providers be alert to the possibility of increased suicide risk among clients who have recently been prescribed antidepressant medications (Sommers-Flanagan & Campbell, 2009).

In the next post in this series I’ll be focusing on Personal and Social factors associated with suicide.

Counseling and Psychotherapy Theory and Practice, Multicultural, Personal Reflections

A Guest Essay on the Girl Code and Feminism

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The past several years I’ve offered a few extra credit points for students in my theories class who write me a short essay on the Girl Code. The Girl Code is defined–using William Pollack’s Boy Code as a guide–as the unhealthy societal and media-based rules by which girls and women are supposed to live. These rules are typically limiting (e.g., women who get angry are considered bitches) and are often damaging to girls and women.

This year students had to watch three feminist-related video clips as a part of this extra credit assignments and then write a short essay. The clips are listed below so you can click on the links and watch them if you like:

Eve Ensler doing a TED talk: Embrace Your Inner Girl — https://www.youtube.com/watch?v=YhG1Bgbsj2w

Emma Watson speaking to the U.N.: https://www.youtube.com/watch?v=c9SUAcNlVQ4

Cameron Russell’s TED talk: http://www.ted.com/talks/cameron_russell_looks_aren_t_everything_believe_me_i_m_a_model?language=en

The following essay was written by Tristen Valentino. He gave me permission to post it here.

I’m featuring Tristen’s essay not only because I found it to be well-written and insightful, but also because his ideas stretch my thinking. Frequently I find myself puzzled as to why so many people in our society have such negative reactions to the word “feminist.” Why would anyone be against equal rights and opportunities for males and females? What’s the problem with that? In fact, this past year Time Magazine went so far as to suggest it be eliminated from the dictionary (inserted stunned silence here). For me, Tristen’s essay is important because, although he strongly criticizes what he sees as the overly generalized messages within the assigned video clips (which I happen to like), he also explicitly condemns the mistreatment of women based on gender.

Here’s Tristen’s essay. I hope you enjoy it . . . or at least find it thought-provoking.

Extra Credit Commentary on Feminism Clips
Tristen Valentino
COUN 485
November 24, 2014

Advocating equal rights is a noble and admirable pursuit. The video clips featuring Eve Ensler, Emma Watson, and Cameron Russell each speak about sexual discrimination, and their own personal roles in feminism. While I fully support equality in opportunity, and applaud their intention, I believe their execution was flawed. The three of them generalized men across the globe, lumping all men from all cultures and nations together in the oppression of women. The three of them claimed that male chauvinism is not only prevalent but pervasive in all societies.

Eve Ensler speaks briefly of her violent and abusive father and alludes that her experiences at the hands of her father set her in motion to help end the victimization of women. In this case I feel that Eve Ensler is looking at everything through the same tinted lens. In her world, the lens with which she views the world is completely blue (victimization of women), so when she looks upon the world she sees everything as blue. While not incorrect, since there are many things blue in the world, this view is incomplete as there are many things not blue. So too with her view on victimization and the causes of it.

Emma Watson’s speech appealed to emotion, but wilted under even slight pressure from a factual basis. She claimed that in her country (United Kingdom) women were oppressed and drew comparisons between the UK and African nations. She failed to mention that in her country the longest serving Prime Minister was a female (Margaret Thatcher) and that the longest living monarch, and second longest reigning monarch, is a female (Queen Elizabeth II).

Cameron Russell speaks about how damaging the media can be to female self-esteem and the female identity. She attributes insecurity, eating disorders, and other self-image issues with fantastical, and often fictional, portrayals of the female form. I find this to be incredibly hypocritical and disingenuous coming from someone who is an active participant in the very mechanism that she claims is doing harm to the female psyche.

However, those issues aside, the issue of gender equality is a serious one, and one that deserves our attention. There is little doubt that acts of female oppression and victimization are completely evil. There is no arguing that in some areas, horrible atrocities happen to women simply because they are women. This culture of male predatory behavior resulting in the victimization of women needs to be addressed and halted immediately. The damage that is caused is not always as easily seen and overt as physical injury. The mental and psychological injuries inflicted by the gender expectations of such things as the “Girl Code” apply pressure to already stressed women to perform up to a standard, and in such a way, as to be unrealistic. Expectations—such as women must always look pretty, must always be as thin as they can be, or must be sexy, but not too sexy—place the value of women on their physical appearance. It prevents their self-expression and their validation of life by stripping away the value of all their other qualities. Women are not objects to be used or abused at the whims of men. Women are not toys to be played with and then discarded. They are equal partners in the venture of life. They are doctors, lawyers, teachers, police officers, and politicians. They are mothers, daughters, sisters, friends, confidants, and mentors. They are strong, intelligent, indomitable, competent, and capable. They are all that and more. They are women. They are human.

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Therapy with Adolescents, Tough Kids Cool Counseling

Non-Drug Options for Dealing with Depression

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

Here’s a short list that might be helpful.

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

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

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

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

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

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

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

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

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

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

John and his sister working on their positive emotions.

Peg and John Singing at Pat's Wedding

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

Neuro-counseling or Neuro-nonsense: You be the judge

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This is a Book Review written by a current doctoral student, Tara Smart and John SF. It was published this past June in the online journal, The Professional Counselor: http://tpcjournal.nbcc.org/

As you may detect, Ms. Smart and I are circumspect about the neuroscience bandwagon.

Here’s the review:

In A Counselor’s Introduction to Neuroscience, the authors claim that “neurocounseling” is the fifth force in the history of psychology and counseling. Although a precise and detailed definition of neurocounseling is elusive (both in this book and in the professional literature), it is described as the marriage of counseling and neurobiology. They offer a crash course in brain anatomy, function, and development in order to lay the groundwork for how neurocounseling can be used effectively with clients. Several chapters focus on the ways the brain is affected by certain mental disorders, and how specific counseling approaches address various brain regions and functions. The remainder of the book focuses on assessment of brain function and fictional cases to illustrate neurocounseling techniques. The chapters include numerous tables, figures, cases and opportunities to stop and reflect. The overall intent of the book is to arm counselors “with yet another highly effective and efficient way to help clients cope with (overcome, etc.) their personal psychological distress.”

Although the authors are clearly enamored with the interaction between neurobiology and counseling, they purposefully offer honest words of caution regarding the nascent and speculative nature of contemporary brain science. However, on occasion, they also make promising statements without citing scientific evidence and generalize results from animal studies (including rodents) to humans without offering their reasoning for doing so. As with any other resource, practitioners are responsible for weighing information and evaluating whether it is accurate and whether it will be helpful in their work. It is important to note that this book bills itself as an “introduction”—readers should not expect concrete or realistic examples of how professional counselors can use their new neuroscience knowledge to understand and enhance client functioning.

A Counselor’s Introduction to Neuroscience will help counselors begin to grapple with the implications of neuroscience for our profession. Although the neuroscience knowledge base that the authors provide is a good start, scientific rigor in terms of concrete application would be useful. Years from now, neurocounseling may well be a new force in counseling, but presenting it to the counseling community as an effective and efficient way to help clients today is premature. In the end, it is best to consider this book as a reasonable beginning and food for thought rather than a how-to guide for counselors seeking neurocounseling training. Hopefully in the ensuing years, there will be clearer guidance available to help professional counselors integrate neuroscience into their practice.

John using his Star Trek tricorder (cell phone) to do a quick selfie brain scan. The results were not promising.

2014-06-03_15-45-11_474

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Reviews of our Counseling and Psychotherapy Theories and Clinical Interviewing DVDs

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For those interested, I’ve put together some information on our Theories and Clinical Interviewing DVDs. Obviously these are positive reviews and I feel shy about posting them, but I also am very happy that these tools for helping people become better counselors and psychotherapists have been so well-received. Thanks to everyone who made these productions possible.

The Theories DVD

From Psychotherapy.net:

Finding a single video demonstrating psychotherapy’s major theoretical orientations has long been next to impossible. Now, Psychotherapy.net is thrilled to offer a masterful survey of the field’s most studied theories to students and instructors alike. You won’t want to miss this video, in which seasoned clinical educators John and Rita Sommers-Flanagan present a practical, in-depth guide through the origins, recent developments, and applications related to eleven major counseling theories, complete with valuable learning aids and extended case studies.

Over the course of eleven compelling segments, the Sommers-Flanagans outline a range of therapeutic orientations, from psychoanalysis to solution-focused therapy and more; each has its own strategies, interventions, and beliefs about the nature of change. Watch John Sommers-Flanagan help 10-year-old Clayton feel better about his “tattletale” brother using an Adlerian family constellation interview. Understand what’s preventing Brittany from attending college classes—and how she can correct this to avoid expulsion—during a behavioral therapy session with Selena Beaumont Hill. See how a feminist approach informs Rita Sommers-Flanagan’s moving work with Amanda, a young woman finding her identity amid a culturally complex web of relationships. And see how family systems therapist Kirsten Murray reengages a stressed family of four in a powerful family sculpt.

Designed for beginners and seasoned therapists alike, this video distills the essence of the major theories of psychotherapy, offering theoretically-grounded interventions and techniques that will be of use to any therapists looking to broaden their toolbox.

Whether you’re a student wanting to understand the basics of different theoretical orientations, a practitioner seeking review materials, or an instructor looking for a single video comparing and contrasting a range of approaches, you’ll find what you need in this comprehensive, one-of-a-kind video.

Theories covered in this video include:
• Psychoanalytic/psychodynamic
• Existential
• Rogerian/Person-Centered
• Gestalt
• Behavior
• Cognitive-Behavioral (CBT)
• Solution-Focused
• Feminist
• Adlerian
• Reality
• Family Systems

Reviews of the Theories DVD from Amazon

1. I just completed my Marriage and Family Psychotherapist graduate program. This book and the DVD helped me to study for my comps.

I recommend that you buy it. I love the way that it is written. Very easy to follow. I really like these two authors. I have other books written by them.

2. There are some horrible counseling instructional videos out there on the market from the 70’s and 80’s and it is hard to find such a rare gem here.

This video can be watched in full screen on a HD television with excellent audio and instructional effects (being able to see counselor’s drawings, written goals, highlights of therapy, etc.). The two authors/producers of this video are also in roughly half of the respective therapies that are gone over. As for behavioral therapy, solutions focused therapy, and family systems they use outside “expert” counselors that do a fantastic job.

I am almost exclusively a visual learner, and this video not only made it simple to understand and grasp all common therapies out there in the professional counseling realm, but also was instrumental in measuring and understanding the intangible traits all good counselors should have (using pause appropriately, asking questions, demeanor, body language, etc.).

3. For the aspiring counselor, this video is worth its weight in gold. Thank you! This DvD is excellent for the classes I teach. It reinforces the students learning. I highly recommend it. Buy it.

4. Thank you Sommers-Flanagans for this great additional resource! Insightful look into the work of masters of the art of therapy.

You can access these DVDs through Wiley: http://lp.wileypub.com/SommersFlanagan/

psychotherapy.net: http://www.psychotherapy.net/

and other online booksellers like Amazon.

The Clinical Interviewing DVD

Professional Reviews:

“Indispensable interviewing skills imparted by two master teachers in an engaging, multimedia presentation. Following the maxim of ‘show and tell,’ the Sommers-Flanagans provide evidence-based, culture-sensitive relational skills tailored to individual clients. An instructional gem!”
— John C. Norcross, PhD, ABPP, Distinguished Professor of Psychology, University of Scranton; Editor, Psychotherapy Relationships That Work

“Before watching this video, I’d considered the text Clinical Interviewing a ‘must-read,’ and now after watching the accompanying video, I consider the book in combination with the video video to be a ‘must-have!’ This video clearly demonstrates essential skills for beginning therapists with a culturally diverse group of clients, and is a valuable resource for training programs and any beginning clinician who wants to be the best they can be!”
— Pamela A. Hays, PhD, Author of Addressing Cultural Complexities in Practice; Supervisor for The Kenaitze Tribe’s Nakenu Family Center, Soldotna, Alaska

From Psychotherapy.net

Simply put, we believe this to be the best video on this topic ever produced, and in fact one of the top training videos in the entire field of psychotherapy and counseling! We’ve been in the business of producing and distributing videos in the field since 1995, so we don’t make this statement lightly. (And we aren’t patting ourselves on the back; we wish we could take credit for this one, but we didn’t actually produce it ourselves.)

Whether you’re just starting out with clients or looking to expand your intake and assessment skills, this comprehensive video with John and Rita Sommers-Flanagan will guide you through the full assortment of clinical interviewing techniques.

This video will help you gain confidence in both the science and the art of the clinical interview, and offer you the “foundation for intuition” that informs therapeutic assessment, intervention, and relationship-building skills.

Skills, steps, and protocols are all covered here, with discussions of multicultural counseling, mental status examinations, and collaborative processes. You’ll also see what not to do with a client, as part of a comical but cautionary demonstration on the pitfalls of directive interventions. For new and experienced clinicians alike, this comprehensive yet accessible video is a must-have in your toolkit.

By watching this video, you will:
• Identify interventions along a continuum of clinical listening responses, from basic to complex.
• Understand the goals and steps of different clinical assessments and examinations.
• Learn tools for establishing and deepening the therapeutic alliance during various types of clinical interventions.

Counseling and Psychotherapy Theory and Practice

A Plan for Maximizing Positive Counseling and Psychotherapy Outcomes

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Sometimes I write things and then forget what I’ve written. Today, as I’m putting together an article for the Journal of Mental Health Counseling, I came across (and then read) a small section from Chapter 1 of our Counseling and Psychotherapy Theories textbook. It’s a little dense (and referenced) for blog material, but otherwise I think it’s a pretty good guide for improving counseling and psychotherapy outcomes. So here it is:

There’s nothing like a good plan to help with goal attainment (see Chapter 9). Using the following plan can help you minimize negative outcomes and maximize positive ones.

1. As appropriate, integrate empirically supported treatments (ESTs) or evidence-based principles (EBPs) into your therapy practice: There are many ESTs, but to use them, you’ll need advanced training, supervision, and it’s impossible to become proficient in the vast array of ESTs available. Therefore, you should learn a few that serve you well as you work with specific populations (e.g., if you want to work with individuals suffering from trauma, learning both Trauma-Focused Cognitive Behavioral Therapy [TF-CBT] and/or Eye Movement Desensitization Reprocessing [EMDR] would be useful). However, there will always be situations where clients don’t perfectly fit a diagnostic category with a specific EST or you don’t think a manualized approach is best, or the client will not want to work using certain approaches. In those cases you should follow EBPs. For example, using Beutler’s systematic treatment selection model, you can systematically select both general and specific approaches that are a good fit for the client and consistent with empirical knowledge about how to address particular problems (Beutler, 2011; Beutler, Harwood, Bertoni, & Thomann, 2006; Beutler, Moleiro, & Talebi, 2002).

2. Understand and capitalize on evidence-based (or empirically supported) relationships and other common factors: As the common factors advocates have articulated so well, evidence exists for much more than psychological interventions or procedures (Norcross & Lambert, 2011). For better or worse, psychological procedures tend to be implemented within the crucible of interpersonal relationships. Consequently, the ethical therapist intentionally attends to the therapeutic relationship in ways consistent with the research base (e.g., by collaboratively setting goals and obtaining consistent feedback from clients about their perceptions of therapy process and content).

3. Avoid pitfalls and procedures associated with negative outcomes: To address potential negative outcomes, ethical therapists should: (a) engage in activities to facilitate awareness including, but not limited to individual supervision, peer supervision, and consistent client feedback; (b) individualize therapy approaches to fit clients—rather than expecting all clients to benefit from a single approach; and (c) avoid using high risk approaches by knowing (and avoiding) potentially harmful therapy (PHT) approaches (Lilienfeld, 2007).

4. Use flexible, but systematic assessment approaches to tailor the treatment to the client and the client’s problem: Much like good mechanics assess the engine before initiating change, ethical therapists conduct some form of assessment prior to using specific therapy interventions. As discussed in each chapter, the particular assessment process you use will likely be more simple or more complex, depending on your theoretical orientation. Nevertheless, empathic, culturally sensitive, and ongoing collaborative assessment helps guide therapeutic processes (Finn, 2009).

5. Use practice-based evidence to monitor your personal therapy outcomes: Practice-based evidence is a term used to describe when clinicians collect data, sometimes every session, pertaining to client symptoms and/or client satisfaction. Duncan, Miller, and Sparks (2004) refer to this process as client informed therapy. Regardless of the terminology, this is a process wherein clients are empowered to directly share their treatment progress (or lack thereof) with their therapists. This allows therapists to make modifications in their approach to facilitate more positive outcomes (Lambert, 2010a; Lambert, 2010b).

Working on positive family bowling outcomes

Bowling

Counseling and Psychotherapy Theory and Practice

Behavioral Activation Therapy: Let’s Just Skip the Cognitions

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This is a short excerpt from the text: Counseling and Psychotherapy Theories in Context and Practice

It describes a research-based behavioral approach to counseling and psychotherapy.

Over half a century ago, Skinner suggested that depression was caused by an interruption of healthy behavioral activities that had previously been maintained through positive reinforcement. Later, this idea was expanded based on the initial work of Ferster (1973) and Lewinsohn (1974; Lewinsohn & Libet, 1972). The focus was on observations that:

“. . . depressed individuals find fewer activities pleasant, engage in pleasant activities less frequently, and obtain therefore less positive reinforcement than other individuals.” (Cuijpers, van Straten, & Warmerdam, 2007, p. 319)

From the behavioral perspective, the thinking goes like this:
1.   Observation: Individuals experiencing depression engage in fewer pleasant activities and obtain less daily positive reinforcement.

2.   Hypothesis: Individuals with depressive symptoms might improve or recover if they change their behavior (while not paying any attention to their thoughts or feelings associated with depression).

Like the good scientists they are, behavior therapists have tested this hypothesis and found that behavior change—all by itself—can produce positive treatment outcomes among clients with depression. The main point is to get clients with depressive symptoms to change their behavior patterns so they engage in more pleasant activities and experience more positive reinforcement
Originally, behavioral activation was referred to as activity scheduling and used as a component of various cognitive and behavioral treatments for depression (A. T. Beck, Rush, Shaw, & Emery, 1979; Lewinsohn, Steinmetz, Antonuccio, & Teri, 1984). During this time activity scheduling was viewed as one piece or part of an overall cognitive behavior treatment (CBT) for depression.
However, in 1996, Jacobson and colleagues conducted a dismantling study on CBT for depression. They compared the whole CBT package with activity scheduling (which they referred to as behavioral activation), with behavioral activation (BA) only, and with CBT for automatic thoughts only. Somewhat surprisingly, BA by itself was equivalent to the other treatment components—even at two-year follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998; Jacobson et al., 1996).

As is often the case, this exciting research finding stimulated further exploration and research associated with behavioral activation. In particular, two separate research teams developed treatment manuals focusing on behavioral activation. Jacobson and colleagues (Jacobson, Martell, & Dimidjian, 2001) developed an expanded BA protocol and Lejuez, Hopko, Hopko, and McNeil (2001) developed a brief (12 session) behavioral activation treatment for depression (BATD) manual and a more recent 10 session revised manual (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011).

Implementation of the BATD protocol is described in a short vignette later in the behavioral theory and therapy chapter in the text: Counseling and Psychotherapy Theories in Context and Practice by John and Rita Sommers-Flanagan. See: http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470617934.html

Or, on Amazon: http://www.amazon.com/John-Sommers-Flanagan/e/B0030LK6NM/ref=ntt_dp_epwbk_1

Several people engaging in behavioral activation therapy at a wedding.

Dancing

 

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

What Kind of a Man Attends the 4th National Psychotherapy with Men Conference?

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Several years ago a former student caught up with me in the hall outside my office in the College of Education at the University of Montana. He had taken an Intro to Psychology course from me way back in 1982. He re-introduced himself, complimented me on my teaching from three decades previously, and then, glancing at my name on the door, asked, “What kind of a man hyphenates his last name?”

I was speechless (which doesn’t happen all that often). He had just told me of his divorce; he had marveled at me being married for 25 years; and yet there it was, a small-dose of straight on masculine-shaming.

I said what most of us probably say when questioned about our masculinity.

I said nothing.

In retrospect, I wish I’d said: “I hyphenated my name because I’m the kind of man who wants to stay married and have a real partnership with his wife.” Hmm. That might have been over-the-top.
I didn’t have a balanced answer then and I’m not sure I have a good one now. But, how about cutting to the chase and meeting his question with one of my own?

“What kind of a man questions another man about his masculinity?”

That might have been fun, but obviously not perfect. And that’s the point; it can be difficult to find the right words in response to comments on our masculinity.

This past Saturday I had the privilege of embracing all dimensions of my humanity, without needing to worry about sideways—or straight on—masculinity comments. That’s because I had the good fortune of attending the 4th National Psychotherapy with Men Conference. Of course, my comfort might have been because the chief conference organizer, Matt Englar-Carlson, a faculty member in the Department of Counseling at Cal State Fullerton, is also a hyphenator. But more likely it was because this particular conference was all about acceptance, inclusion, listening, understanding, learning . . . and most of all CONNECTION. Masculine shaming was nowhere in the room.

The conference organizers, Englar-Carlson, David Shepard, and Rebekah Smart, set the tone for understanding and inclusiveness in their opening comments. The opening keynote followed and it was BY A WOMAN . . . which this leads me to back to my masculine-shaming theme for today:

“What kind of a MEN AND MASCULINITY organization sponsors a conference on psychotherapy with men and then has an opening keynote speech BY A WOMAN?”

Answer: “The kind of organization populated by people who have the good judgment to be very interested in listening to and understanding women’s perspectives.”

And so we all got to listen to—not just any woman (although that would have been fine too, because the conference wasn’t about status)—but the renowned Judith Jordan, author of many books and co-director of the Jean Baker Miller Institute. How cool is that?

After Jordan explored how we can raise boys to be competent and connected men, we scattered to different break-out sessions. As my adolescent clients would say, this sucked because it’s hard to make hard choices. My principle regret of the whole conference was that even though I have two last names, there’s still only one of me and so I couldn’t attend EVERY SESSION, but instead had make choices. And although I was perfectly happy to start my break-out experiences listening to Christopher Kilmartin, professor of psychology at the University of Mary Washington, as Irvin Yalom would say, it meant the death of the rest of my choices.

But seriously . . . here’s the important question: “What kind of a man accepts a faculty position at an institution named THE UNIVERSITY OF MARY WASHINGTON?”

Answer: “The same kind of man who gets asked to spend a year teaching sexual assault prevention at the Air Force Academy.” Now that’s a pretty good answer.

Kilmartin was awesome (just ask my wife, because I’ve been quoting him all week). But being at his break-out session made me miss the amazing Jon Carlson who might be the kindest, gentlest, and most humble person I know with hundreds of professional publications, video productions, and spare time to raise five children (two adopted) including the hyphenated conference organizer, who happens to have full professor status despite looking like he just shaved for the first time last week.

Naturally, the psychotherapy with men conference lunch had a vegetarian option (at this point I should also mention the Starbucks coffee and whole wheat bagels in the morning and the Panera coffee and cookies in the afternoon). Right after lunch, we gathered to listen to Fredric Rabinowitz, the afternoon keynote. Rabinowitz, who also happens to play tournament poker, talked about Deepening Psychotherapy with Men. He emphasized that, for men, there’s a substantial vocabulary about defenses, but not Department of Connection. For the past 20+ years he has helped men go deep and express their pain and loss in ways that are (surprise!) contrary to how society expects men to express their pain and loss. Unfortunately, Rabinowitz had to miss an annual fancy poker tournament to attend the conference . . . which leads to the obvious question:

“What kind of a man misses a poker tournament to talk with a bunch of sensitive psychotherapy-types?”

Answer: “A pretty cool dude who knows his priorities.”

After Rabinowitz’s keynote, there were more decisions. In my program I had circled presentations by David Shepard and Michele Harway as well as Chris Liang. But I should confess here-and-now that I got slightly intoxicated with Panera coffee and cookies and ended up wandering into the wrong room with three Canadian presenters who were talking about how to help men transition from military to civilian life. It might have partially been the coffee, but the Three Canadians ROCKED MY WORLD . . . which begs the question:

“What kind of a man gets his world rocked by Three Canadians?”

Answer: “The kind of man who recognizes they have such fabulous clinical skills and compassion and cleverness that it makes him wish he was born and raised in Vancouver, B.C. instead of Vancouver, Washington (not that there’s anything wrong with Vancouver, WA).”

After my Canadian experience I staggered into Mark Stevens’s presentation on Engaging Men in the Process of Psychotherapy. Stevens showed photos of little boys and asked us to remember that ALL OF OUR MALE CLIENTS were once sensitive boys (not little men). He urged us to engage men slowly, but to not judge or underestimate them in ways that minimize or shrink their humanity. This was awesome, but I have to ask:

“What kind of a man shows photos of little boys during a professional presentation?”

Answer: “The kind of man who understands how to work effectively with men.”

At this conference you didn’t need a hyphenated name and you didn’t need an un-hyphenated name, because there was no shaming either way. There was just acceptance; acceptance of being scared boys and scared girls who are doing the best we can to openly affirm and connect with each other. And these connections reached across races, to the transgendered, to the women, and even to graduate students. If you’re interested in this sort of thing (and I think you should be), you should check out Division 51 of the American Psychological Association at: http://www.division51.org/

BTW, at the post-conference social I got to meet lore m. dickey, who presented earlier in the day on Affirmative Practice with Transgender Clients. He immediately shared with me that he is a female to male transsexual. That’s the sort of openness and connection you get at the Psychotherapy with Men conference. But I’m sure you know this leads me to another purposely masculinity-shaming question.

“What kind of a man chooses to go through a female to male transgender process?”

“The kind of a man who has achieved clarity about his male identity.”

The day ended with me hanging out with the Three Canadians—whom I should name here (Marvin Westwood, David Kuhl, and Duncan Shields). They welcomed me to their table at the social time where we engaged in an extended international mutual appreciation festival. You should really look them up.

All this brings me to my final question:

“What kind of a man writes an fluffy, complimentary, and sycophantic blog about the 4th National Psychotherapy with Men Conference?”

Answer: “The kind of man who wants to offer the conference organizers and participants the thanks and praise they deserve.”