Category Archives: Counseling and Psychotherapy Theory and Practice

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.”

 

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

Webinar Tomorrow: Diagnosis and Assessment of Oppositional Defiant Disorder and Conduct Disorder

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Tomorrow at noon Mountain Time, Western Montana Addiction Services is sponsoring a one-hour webinar on the diagnosis and assessment of oppositional defiant disorder and conduct disorder. I’ll be the presenter. If you’re interested in tuning in, you’ll need to email Erin Wenner at: ewenner@wmmhc.org to get instructions on how to gain access. This month I’ll be focusing on very basic diagnosis and assessment issues related to ODD and CD. Next month on June 10th at noon, I’ll be focusing counseling or treatment issues.

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

Handling Termination in Counseling and Psychotherapy

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It’s that time of the year (at most colleges and universities) when those of us doing and supervising counseling and psychotherapy should be thinking about how to handle termination. Well, actually we should have been thinking about it before, but if not then, now is good.

Anyway, I just sent the following termination checklist out to my MA and Doc students here at U of MT and thought this could be helpful for others, so here it is. Keep in mind that it was written for working with youth, but can be modified to stimulate your thinking about termination with whatever population with which you work.

Termination Content Checklist

[Adapted from Sommers-Flanagan, J., and Sommers-Flanagan, R., (2007).
Tough Kids, Cool Counseling: User-Friendly Approaches with Challenging Youth.
Alexandria, VA: American Counseling Association]

The following termination content checklist may be helpful for you as you plan for counseling or plan for termination. Keep in mind that this is not a comprehensive checklist that you MUST complete at the end of counseling. Also, keep in mind that the sample statements are just samples and that you should find your own words for expressing these (or similar) things. The point is that this is a guide to help you think about termination—even though some of the details will be different for you and your client(s).

_____ 1. At the outset and throughout counseling, the counselor identifies progress toward termination (e.g., “Before our meeting today, I noticed we have 4 more sessions left,” or “You are doing so well at home, at school, and with your friends. . . let’s talk about how much longer you’ll want or need to come for counseling”).
_____ 2. The counselor reminisces about early sessions or the first time counselor and client met. For example: “I remember something you said when we first met, you said: ‘there’s no way in hell I’m gonna talk with you about anything important.’ Remember that? I have it right here in my notes. You were sure excited about coming for counseling” (said with empathic sarcasm).
_____ 3. The counselor identifies positive behavior, attitude, and/or emotional changes. This is part of the process of providing feedback regarding problem resolution and goal attainment: “I’ve noticed something about you that has changed. It used to be that you wouldn’t let adults get chummy with you. And you wouldn’t accept compliments from adults. Now, from what you and your parents tell me and from how you act in here, it’s obvious that you give adults a chance. You aren’t always automatically nasty to every adult you see. I think that’s nice.”
_____ 4. Acknowledge that the relationship is ending with counseling termination: “Next session will be our last session. I guess there’s a chance we might see each other sometime, at the mall or somewhere. If we see each other, I hope it’s okay for us to say hello. But I want you to know that I’ll wait for you to say hello first. And of course, I won’t say anything about you having been in counseling.”
_____ 5. Identify a positive personal attribute that you noticed during counseling. This should be a personal characteristic separate from goals the client may have attained: “From the beginning I’ve always enjoyed your sense of humor. You’re really creative and really funny, but you can be serious too. Thanks for letting me see both those sides. It took courage for you to seriously tell me how you really feel about your mom.”
_____ 6. If there’s unfinished business (and there always will be) provide encouragement for continued work and personal growth: “Of course, your life isn’t perfect, but I have confidence that you’ll keep working on communicating well with your sister and those other things we’ve been talking about.” You may want to explicitly describe how your client doesn’t “need” counseling, but that continued counseling or counseling in the future might be helpful: “You know some people come to counseling to work on big problems; other people come because they find counseling can be useful and help them move toward personal growth or greater awareness; and other people just like counseling. You might decide you want to continue in counseling or start up again for any of these reasons.”
_____ 7. Provide opportunities for feedback to you: “I’d like to hear from you. What did you think was most helpful about coming to counseling? What did you think was least helpful?” You can add to this any genuine statements about things you wish you’d done differently as long as it’s not based on new insights. For example, if your client got angry for you for misunderstanding something and this was processed earlier, you might say: “And of course I wish I had heard you correctly and understood you the first time around on that [issue], but I’m glad we were able to talk through it and keep working together.”
_____ 8. If it’s possible, let the client know that he or she may return for counseling in the future: “I hope you know you can come back for a meeting sometime in the future if you want or need to.”
_____ 9. Make a statement about your hope for the client’s positive future: “I’ll be thinking of you and hoping that things work out for the best. Of course, like I said in the beginning, I’m hoping you get what you want out of life, just as long as it’s legal and healthy.”
_____ 10. As needed, listen to and discuss client wishes about continuing counseling forever or client wishes about transforming their relationship with you from one of counselor–client to that of parent–child or friend: “Like you’ve known all along, counseling is kind of weird. It’s not like we’re mom and daughter or aunt and niece. And even though I like you and feel close to you, it isn’t really the same as being friends” (further discussion and processing of feelings follows).

For more information on termination with youth, go to: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_3?s=books&ie=UTF8&qid=1396895008&sr=1-3

 

 

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections

Listening as Meditation on Psychotherapy.net

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Listening in psychotherapy and counseling is partly art and partly science. This week I have the good fortune of having a blog piece I wrote on Listening as Meditation published at psychotherapy.net. You can access this blog piece — and other excellent psychotherapy.net blog pieces — at: http://www.psychotherapy.net/blog

Have an excellent and mindful Wednesday.

John SF

Counseling and Psychotherapy Theory and Practice

How to Use the Six Column CBT Technique

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A Description of the Six Column CBT Technique

In contrast to popular belief, CBT requires counselors to be warm and compassionate. Also, the focus of CBT is on experiential psychoeducation. Aaron Beck emphasized collaborative empiricism. Never forget that term. Collaborative empiricism is the bedrock of good CBT. It emphasizes the process of counselors and clients working together to test the accuracy and usefulness of specific thoughts and behaviors. As a therapeutic process, collaborative empiricism is also central to Person-Centered and Motivational Interviewing approaches. Remember: We want the client to have a central role in determining the usefulness and dysfunctionality of his or her cognitions and behaviors.

The six column technique is simply a procedure that helps clients and counselors organize, explore, and discover how situations, thoughts/beliefs, emotions, behaviors, and emotional/interpersonal/psychological outcomes are inter-related. This is my own particular version of the six column technique. It’s derived from the work of Aaron Beck, Albert Ellis, Judith Beck, and other cognitive behavioral therapists. You can see a short clip of me using this technique at: https://www.youtube.com/watch?v=jfVeeGJHFjA

Here’s a description of the six columns:

Column #1: The Situation

BE THINKING ABOUT LINKING EMOTIONS TO SPECIFIC SITUATIONS

It may be that you’ll begin with whatever emotional distress the client is experiencing or reporting. Or you may begin with thoughts and beliefs that are clearly linked to specific client emotions and behaviors. Or you may begin with the situation or “trigger” for the cognitions and subsequent emotions.

Here’s an example of a situation as reported by a client:

“My in laws are staying in my home     .”

“They’re messy and lazy and I have to pick up after them”

Column #2: Automatic Thoughts and Automatic Behaviors

HELP CLIENTS SEE THAT AUTOMATIC THOUGHTS ARE OFTEN THE BRIDGE BETWEEN SITUATIONS AND EMOTIONS

Here are some examples of the automatic thoughts the clients thinks when she faces the previously described situation:

“They’re old enough to pick up after themselves.”

“Sometimes I stand in front of the television they’re watching to block their view as I pick their stuff up.”

Sometimes if “she” says she’ll do the dishes, I say, “No thanks. I want them to get done in the next two weeks.”

REMEMBER THAT AN EXPLORATION OF YOUR CLIENTS AUTOMATIC THOUGHTS AND BEHAVIORS OFTEN WILL SHED LIGHT ON DEEPER CORE BELIEFS ABOUT THE SELF, THE WORLD, AND THE FUTURE.

Column #3: Emotions and Sensations

SOMETIMES IT IS VERY NATURAL TO START HERE BECAUSE YOUR CLIENT’S EMOTIONS AND SENSATIONS MAY BE A WAY THAT THE MIND AND BODY ARE VOICING HIS OR HER DISTRESS (or you may find the best entry point into the six column technique is somewhere else)

Here are the ratings and descriptions the client provided for column #3:

Anger = 75 (on a 0-100 scale with 0 = totally mellow and 100 = explosive distress)

Discomfort = 75

EMOTIONS AND SENSATIONS MAY BE WHAT IS MOST TROUBLING TO CLIENTS AND THAT’S WHY THEY’RE TYPICALLY RE-EXAMINED IN COLUMN #6: NEW OUTCOMES

Column #4: Helpful Thoughts

HELPFUL THOUGHTS ARE ALSO SOMETIMES REFERRED TO AS “COOL THOUGHTS.” THIS IS ESPECIALLY TRUE WHEN WORKING WITH ANGER AND AGGRESSION BECAUSE COOL THOUGHTS HELP CALM OR COOL OFF THE ANGER AND REDUCE THE POTENTIAL FOR AGGRESSION.

Here are some thoughts that the client identified as helpful. Helpful thoughts are often seen as adaptive or more accurate or more “rational” (which is an Albert Ellis term).

“This is important for my husband.”

“I can see this as a challenge for me to become more direct and assertive.”

“They mean well.”

A WAY OF ASKING ABOUT HELPFUL THOUGHTS IS TO JUST ASK DIRECTLY: WHAT ARE SOME THOUGHTS OR BELIEFS THAT YOU THINK WOULD BE HELPFUL TO YOU IN THIS SITUATION? YOU MAY NEED TO HELP CLIENTS WITH THIS BY PROVIDING EXAMPLES . . . BUT NOT BY TELLING THEM WHAT THEY SHOULD THINK. ENCOURAGE THEM TO FIND THEIR OWN WORDS.

Column #5: Helpful Behaviors

SIMILAR TO THE PRECEDING COLUMN, WE CAN THINK OF BEHAVIORS AS “HOT” OR “COOL” BEHAVIORS. HOT BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS WORSE; COOL BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS BETTER.

Here are some behaviors the clients said she thought might be helpful:

“I could sit down and talk with them about picking up their messes at a regular time.”

“I could ask my husband to talk with them.”

“I could go to a Yoga class two nights a week.”

WHEN IT COMES TO BOTH HELPFUL THOUGHTS AND HELPFUL BEHAVIORS, IT’S USEFUL TO THINK OF THEM AS OCCURRING (A) BEFORE, (B) DURING, OR (c) AFTER THE SITUATION ARISES. SOME BEHAVIORS (E.G., GETTING ENOUGH SLEEP) HELP THE SITUATION AS A PROACTIVE OR PREVENTATIVE ACTION. OTHER BEHAVIORS (E.G., DEEP BREATHING) MAY BE CRUCIAL DURING THE SITUATION. STILL OTHER BEHAVIORS (E.G., VENTING TO A FRIEND OR PROVIDING SELF-REINFORCEMENT) MAY BE HELPFUL AFTER THE SITUATION IS OVER.

Column #6: New Outcomes

AFTER IMPLEMENTING THE HELPFUL COGNITIONS AND HELPFUL BEHAVIORS, IT’S A GOOD IDEA TO RE-EVALUATE THE CLIENT’S EMOTIONS AND SENSATIONS (OR DISTRESS).

In this case, the client provided the following ratings:

Anger = 40

Discomfort = 40

ONE OF THE GOALS OF CBT IS TO REDUCE DISTRESS AND REDUCE SYMPTOMS AND MAKE LIFE A LITTLE BETTER. YOU MAY NOT CREATE VAST IMPROVEMENTS, BUT IMPROVEMENTS ARE IMPROVEMENTS. THIS IS ALSO JUST THE BEGINNING OF CBT (OR WHATEVER APPROACH YOU’RE USING) BECAUSE THE WHOLE POINT IS THAT LIFE IS AN EXPERIMENT AND THAT WE COLLABORATIVELY AND INTERACTIVELY ARE HELPING CLIENTS TRY OUT NEW THOUGHTS AND BEHAVIORS THAT MAY (OR MAY NOT) LEAD TO IMPROVEMENT. AND IF THE IMPROVEMENT ISN’T OPTIMAL . . . THE CBT WAY IS TO GO BACK TO THE BEGINNING AND REWORK THE PROCESS TO SEE IF FURTHER IMPROVEMENTS CAN OCCUR.

CBT Tips

Here are a few tips on how to integrate CBT in your work.

Some counselors or mental health professionals resist using CBT and complain that it’s too sterile or too educational or not focused enough on feelings. Basically, I think this is a cop-out similar to CBT folks who say that person-centered therapy is ineffective. My belief (and I think it’s rational and so it must be (smiley face) is that when mental health professionals don’t understand how to implement a particular approach, they blame the approach rather than admitting their lack of knowledge or skill. Instead, I encourage you to try this six column CBT model, but use it with whatever other model you prefer. In other words, you can be a person-centered CBT person or an existential CBT person . . . especially if you just use this six column technique as a means for exploring and understanding different dimensions of your client’s personal experience.

Goal-setting is essential to counseling. From the CBT perspective, goal-setting is initiated by generating a problem list. However, your IR clients may not have a problem listJ. That’s why you may need to use your excellent active listening skills to help your clients focus in on a distressing emotion. Then you can begin with the distressing or disturbing emotion and build the six columns from there.

Good CBT involves adopting an experimental mindset (never forget collaborative empiricism). All you’re doing is helping your client look at his/her daily experiences and identify patterns. It helps to organize the client’s experience into Situation, Automatic Thoughts/Behaviors, Emotions and Sensations, Helpful (Cool) Thoughts, Helpful (Cool) Behaviors, and New Outcomes. You can explore these common dimensions of human experience collaboratively.

It’s very important to know and remember that giving behavioral assignments can be disastrous. This is part of why a good CBT counselor is better than a technician. If you’re brainstorming possible helpful behaviors, your client (and you) may zero in on a behavior that, if enacted, has a strong possibility of a negative outcome. New behaviors expose clients to risk. The risk may be worth it; but there also may be too much risk.

Avoid asking questions like: “Have you thought about talking directly to your in-laws?” This sort of question implies that your client should talk directly to the in-laws. It’s better to step back and brainstorm behavioral options with your client. Then, emphasize that behavioral goals must always be in the client’s control. Then, after your nice list of behavioral options has been generated, you can look at the different options and engage in “consequential thinking.” In other words, you ask your client to explore the possibilities of what is likely to happen if: “You (the client) directly confront the in-laws about their messy behaviors? “ (See sample six column worksheet).

There are many ways you can get to your client’s underlying core beliefs or cognitive dynamics. For example, you could ask: “What stops you from telling them to pick up after themselves?” The client might respond with a different emotion and new content (e.g., I’m afraid of getting into a conflict). You can pursue this further: “What is it about being in conflict makes it scary?” She might say, “I’m afraid my husband will side with them and leave me.” As a consequence, this conflict is viewed as something she needs to manage independently and gets at a deeper schema: “I must keep the peace and deal with everything or bad things (e.g., abandonment) will happen.” There are two problems with this: (a) If she overfunctions she feels angry and acts passive-aggressively; and (b) there may be truth to this schema/belief. This is why we can’t just push her into being assertive. We must always keep the corrective emotional experience rule in mind. New behavioral opportunities need to be free from the likelihood of re-traumatization.

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

What You Missed in Cincinnati: Part II

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While in Cincinnati, I ran short on time and we missed a chance to watch a video clip on “Generating Behavioral Alternatives.” And so as a substitute, I’m posting the verbatim script of the clip we were supposed to watch, and although we’ll miss out on discussing, the clip is fun on its own. Here it’s an excerpt from our Counseling and Psychotherapy Theories book and placed in the context of “Problem-Solving Therapy.”

Generating Behavioral Alternatives With an Aggressive Adolescent

As noted previously, problem-solving therapy (PST) focuses on teaching clients steps for rational problem solving. In this case vignette, the therapist (John) is trying to engage a 15-year-old White male client in stage 2 (generating solutions) of the problem-solving model. At the beginning of the session, he client had reported that the night before, a male schoolmate had tried to rape his girlfriend. The client was angry and planning to “beat the s*** out” of his fellow student. During the session, John worked on helping the boy identify behavioral alternatives to retributive violence.

The transcript below begins 10 minutes into the session.

Boy: He’s gotta learn sometime.

JSF: I mean. I don’t know for sure what the absolute best thing to do to this guy is . . . but I think before you act, it’s important to think of all the different options you have.

Boy: I’ve been thinking a lot.

JSF: Well, tell me the other ones you’ve thought of and let’s write them down so we can look at the options together.

Boy: Kick the shit out of him.

JSF: Okay, I know 2 things, actually maybe 3, that you said. One is kick the [crap] out of him, the other one is to do nothing . . .

Boy: The other is to shove something up his a**.

JSF: And, okay—shove—which is kinda like kicking the s*** out of him. I mean to be violent toward him. [Notice John is using the client’s language.]

Boy: Yeah, Yeah.

JSF: So, what else?

Boy: I could nark on him.

JSF: Oh.

Boy: Tell the cops or something.

JSF: And I’m not saying that’s the right thing to do either. [Although John thinks this is a better option, he’s trying to remain neutral, which is important to the brainstorming process; if the client thinks John is trying to “reinforce” him for nonviolent or prosocial behaviors, he may resist brainstorming.]

Boy: That’s just stupid. [This response shows why it’s important to stay neutral.]

JSF: I’m not saying that’s the right thing to do . . . all I’m saying is that we should figure out, cause I know I think I have the same kind of impulse in your situation. Either, I wanna beat him up or kinda do the high and righteous thing, which is to ignore him. And I’m not sure. Maybe one of those is the right thing, but I don’t know. Now, we got three things—so you could nark on him. [John tries to show empathy and then encourages continuation of brainstorming.]

Boy: It’s not gonna happen though.

JSF: Yeah, but I don’t care if that’s gonna happen. So there’s nark, there’s ignore, there’s beat the s**. What else?

Boy: Um. Just talk to him, would be okay. Just go up to him and yeah . . . I think we need to have a little chit-chat. [The client is able to generate another potentially prosocial idea.]

JSF: Okay. Talk to him.

Boy: But that’s not gonna happen either. I don’t think I could talk to him without, like, him pissing me off and me kicking the s*** . . . [Again, the client is making it clear that he’s not interested in nonviolent options.]

JSF: So, it might be so tempting when you talk to him that you just end up beating the s*** out of him. [John goes back to reflective listening.]

Boy: Yeah. Yeah.

JSF: But all we’re doing is making a list. Okay. And you’re doing great. [This is positive reinforcement for the brainstorming process—not outcome.]

Boy: I could get someone to beat the s*** out of him.

JSF: Get somebody to beat him up. So, kind of indirect violence—you get him back physically—through physical pain. That’s kind of the approach.

Boy: [This section is censored.]

JSF: So you could [do another thing]. Okay.

Boy: Someone like . . .

JSF: Okay. We’re up to six options. [John is showing neutrality or using an extinction process by not showing any affective response to the client’s provocative maladaptive alternative that was censored for this book.]

Boy: That’s about it. . . .

JSF: So. So we got nark, we got ignore, we got beat the s*** out of him, we got talk to him, we got get somebody else to beat the shit out of him, and get some. . . . [Reading back the alternatives allows the client to hear what he has said.]

Boy: Um . . . couple of those are pretty unrealistic, but. [The client acknowledges he’s being unrealistic, but we don’t know which items he views as unrealistic and why. Exploring his evaluation of the options might be useful, but John is still working on brainstorming and relationship-building.]

JSF: We don’t have to be realistic. I’ve got another unrealistic one. I got another one . . . Kinda to start some shameful rumor about him, you know. [This is a verbally aggressive option which can be risky, but illustrates a new domain of behavioral alternatives.]

Boy: That’s a good idea.

JSF: I mean, it’s a nonviolent way to get some revenge.

Boy: Like he has a little dick or something.

JSF: Yeah, good, exactly. [John inadvertently provides positive reinforcement for an insulting idea rather than remaining neutral.]

Boy: Maybe I’ll do all these things.

JSF: Combination.

Boy: Yeah.

JSF: So we’ve got the shameful rumor option to add to our list.

Boy: That’s a good one. (Excerpted and adapted from J. Sommers-Flanagan & R. Sommers-Flanagan, 1999)

This case illustrates what can occur when therapists conduct PST and generate behavioral solutions with angry adolescents. Initially, the client appears to be blowing off steam and generating a spate of aggressive alternatives. This process, although not producing constructive alternatives, is important because the boy may be testing the therapist to see if he will react with judgment (during this brainstorming process it’s very important for therapists to remain positive and welcoming of all options, no matter how violent or absurd; using judgment can be perceived and experienced as a punishment, which can adversely affect the therapy relationship). As the boy produced various aggressive ideas, he appeared to calm down somewhat. Also, the behavioral alternatives are repeatedly read back to the client. This allows the boy to hear his ideas from a different perspective. Finally, toward the end, the therapist joins the boy in brainstorming and adds a marginally delinquent response. The therapist is modeling a less violent approach to revenge and hoping to get the boy to consider nonphysical alternatives. This approach is sometimes referred to as harm reduction because it helps clients consider less risky behaviors (Marlatt & Witkiewitz, 2010). Next steps in this problem-solving process include:

  • Decision making
  • Solution implementation and verification

As the counseling session proceeds, John employs a range of different techniques, including “reverse advocacy role playing” where John plays the client and the client plays the counselor and provides “reasons or arguments for [particular attitudes] being incorrect, maladaptive, or dysfunctional” (A. M. Nezu & C. M. Nezu, 2013).

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

Why Evolution is a Bad Explanation for Human Behavior

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Nearly every day I hear, read, or see the latest news story about how the human brain is hard-wired to make all humans act in one particular way or another. These stories annoy me because:

  1. They emphasize that all humans are the same and ignore the fact that we’re all unique and, to a large degree, unpredictable.
  2. They imply that humans are unlikely to change or deviate from one another.
  3. They repeatedly claim we’re all hard-wired despite the fact that the human brain has NO WIRES.

Even worse, at the bottom of most of these “Your brain is hard-wired” stories is a mythical evolutionary explanation. This annoys me even more . . . because when it comes to everyday human behavior, evolution makes for very bad explanations. But if you’re listening to what pundits and scientists say in the media, you’d be inclined to believe the opposite of what’s really true about humans.

For mysterious reasons, many scientists—especially evolutionary scientists—want to put humans in a box. They suggest and imply and assert that human behavior is predictable. But the truth is that—apart from breathing—there are very few predictable human behaviors. As decades of controlled psychological experiments have shown, even under laboratory conditions where little choice is possible, scientific predictions typically account for no more that 30-40% of the variation in human behavior. This means that humans are 60-70% unpredictable . . . even under highly controlled conditions.

Aside from being mostly wrong, simple evolutionary and biological explanations for human behavior also often are translated into messages that are generally unhealthy for society. Let’s take one big example.

An especially popular media and science topic is male sexual behavior. The argument usually goes like this: Over millions of years males have become hardwired to be attracted to fertility and novelty in sexual partners. This is because . . . the argument continues . . . males seek to perpetuate their gene-pool. This is why, they say, males are attracted to younger females who exhibit signs of reproductive health. This also explains why males—especially young males—are driven to have sex with multiple female partners.

Given current U.S. social problems—think sexual assault and high divorce rates—it makes little sense to promote the mostly false ideas that males seek sexual novelty to perpetuate their gene pool. This information is unhelpful to women who want safe and stable relationships with men and it’s unhelpful to the majority of men who—in contradiction to evolutionary theory—want safe and monogamous intimate relationships with women (or other men).

Most of the time, most males engage in sexual behavior that’s not at all designed to spread their seed or perpetuate their gene pool. Young men are often strongly motivated to NOT get their girlfriends pregnant. Recent data indicate that many young men are NOT especially interested in engaging in indiscriminate sexual behavior.

Even in a 2011 research study at Syracuse University, 333 undergraduate males apparently hadn’t gotten the memo about being hardwired to want sex with novel partners. When asked, whether they could “. . . imagine themselves enjoying casual sex” these young men showed an average response that was largely in the “undecided” range. Think about that: males from 18-22 years-old at Syracuse University couldn’t really decide if they might enjoy casual sex. This is good news. And it’s not consistent with evolutionary-based myths about contemporary young men.

In the same study, 300+ Syracuse University women reported—in direct contradiction to evolutionary theory—that they had been engaging in casual sexual encounters at approximately the same rate as the males.

And so next time you hear or read or view a media story about how millions of years of evolution explains why human males or females behave one way or another, remember that many immediate conditions can and do override evolutionary-based predictions. Evolution is a generality that may or may not apply to a single organism living in the 21st century. Evolution does not trump choice. And that’s the point: Your choices tomorrow will have much more to do with the situations you’re facing today (and that you’re anticipating tomorrow) than they’ll have to do with yesterday.

Counseling and Psychotherapy Theory and Practice

Feminist Culture in Music

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This afternoon I’m doing a guest lecture for Sidney Shaw on Feminist Theory and Therapy. In honor of this, I’m posting an excerpt from our “Study Guide” for Counseling and Psychotherapy Theories in Context and Practice. Here you go:

Most dominant cultural media is clearly NOT feminist. A quick perusal of movie trailers (which generally include men with guns and women quickly undressing because they’re so darn aroused by men with guns) or popular music filtering into the ears of our youth will affirm this not-so-radical-reality.

For this activity we were interested in music, films, and books that ARE feminist in orientation and so we conducted a non-random survey of participants on counseling and psychology listservs and online blogs. We simply asked: Please share your recommendations for first, second, and third wave feminist songs, films, and books (and then did a few online searches). Interestingly, the most significant finding was that listserv respondents clearly had a much stronger passion for music than anything else. We received only one book recommendation and one film recommendation. In contrast, we got flooded by song recommendations. Consequently, we decided to focus our survey specifically on songs and will leave the books and films for another project.

Before we get to our non-comprehensive and nonrandom feminist song list, we should briefly discuss the three waves of feminism . . . despite the fact that doing so may raise issues and stimulate debate. No doubt, individuals who experienced or are knowledgeable about each wave may take issue with the distinctions offered below. Nevertheless, here’ son look (Susan Pharr, 1997) at the evolution of feminism:

We are examining sexism, racism, homophobia, classism, anti-Semitism, ageism, ableism, and imperialism, and we see everything as connected. This change in point of view represents the third wave of the women’s liberation movement, a new direction that does not get mass media coverage and recognition. It has been initiated by women of color and lesbians who were marginalized or rendered invisible by the white heterosexual leaders of earlier efforts. The first wave was the 19th and early 20th century campaign for the vote; the second, beginning in the 1960s, focused     on the Equal Rights Amendment and abortion rights. Consisting of predominantly white middleclass women, both failed in recognizing issues of equality and empowerment for all women. The third wave of the movement, multi-racial and multi-issued, seeks      the transformation of the world for us all. (p.26)

If we go with Pharr’s distinctions, we would broadly categorize first, second, and third wave feminism as:

 

  1. Campaign for the vote
  2. The ERA and abortion rights
  3. Multi-racial, multi-issued world transformation

 

What’s problematic about this categorization is that it’s too darn simplistic. The vote, ERA, and abortion rights were key or central issues, but first and second wave feminists we know would take issue with the narrowness of this depiction and would rightly point to first and second wave feminist efforts at including—not marginalizing—minority groups.

With this in mind, although we initially anticipated creating a nuanced and organized Table with books, films, and songs tightly organized by their connection with a particular “feminist wave” we’ve now decided to make a less organized list of feminist-oriented songs that have inspired individual women and men. And while the less organized list is perhaps less satisfying to our more compulsive sides, it also provides freedom for you as a reader to listen to the music, appreciate or explore the various messages, and then categorize or refuse to categorize the songs based on your preference. In the end, we found ourselves a little surprised to find that this less categorical, more dimensional, and more personal approach feels more consistent with feminist ideals . . . ideals that focus on the personal as political and that assert that authority figures should resist the impulse to tell others what and how to think.

As you read through these recommendations we suggest you think about what songs hold meaning for you and why. Along with many of the recommendations listed, we also received explanations for why the particular song was meaningful—in a feminist way. There’s always space in any list for additions and subtractions and your personal additions and subtractions might help you create an inspiring feminist playlist for yourself.

One final caveat: When we searched online for top feminist songs and anthems, we came across the occasional angry blog or posting demonizing the feminist perspective. We found this a little creepy and a little fascinating. One example was a comment (we’re paraphrasing now) about the heathen feminists . . . who sing into microphones and sound systems all of which were ‘invented’ by men. We include this comment primarily to emphasize that, in fact, you also may find yourself having strong emotional reactions to the music or the lyrics or the preceding comment. If your reactions are especially strong, we recommend you conduct a feminist power analysis and/or have a discussion about your reactions with someone you trust (and who has a balanced feminist perspective).

 

Table 10.1: A List of Feminist Songs that Counselors and Psychotherapists have Found Inspiring

 

18 Wheeler – Pink

A Sorta Fairytale – Tori Amos

Alien She – Bikini Kill

All American Girl – Melissa Etheridge

Ampersand – Amanda Palmer

Androgynous – Joan Jett

Be a Man – Courtney Love

Beautiful Flower – India Arie

Beautiful Liar – Beyonce and Shakira

Been a Son – Nirvana

Black Girl Pain – Jean Grae and Talib Kweli

Butyric Acid – Consolidated

Can’t Hold Us Down – Christina Aguilera

Cornflake – Tori Amos

Crucify – Tori Amos

Daughter – Pearl Jam

Double Dare Ya – Bikini Kill

Express Yourself – Madman

Fixing her Hair – Ani Difranco

Glass Ceiling – Metric

God – Tori Amos

Gonna Be an Engineer – Peggy Seeger

Goodbye Earl – The Dixie Chicks

He Thinks He’ll Keep Her – Mary Chapin Carpenter

Hey Cinderella – Suzy Bogguss

Human Nature – Madonna

I am Woman – Helen Reddy

I Will Survive – Gloria Gaynor

I’m a Bitch – Meredith Brooks

I’m Every Woman – Chaka Khan or Whitney Houston

It’s a She Thing – Salt and Peppa

Just a Girl – No Doubt

Man! I Feel Like a Woman – Shania Twain

Me and a gun – Tori Amos

My Old Man – Joni Mitchell

No More Tears – Barbra Streisand and Donna Summer

Not a Pretty Girl – Ani Difranco

Not Ready to Make Nice – The Dixie Chicks

One of the Boys – Katy Perry

Poker Face – Lady Gaga

Pretty Girls – Neko Case

Professional Window – Tori Amos

Promiscuous – Nelly Furtado

Rebel Girl – Bikini Kill

Respect – Aretha Franklin

Silent All these Years – Tori Amos

Sisters are Do – Aretha Franklin and Annie Lennox

Sisters are Doing It for Themselves – Aretha Franklin and the Eurythmics

Spark – Tori Amos

Stronger – Britney Spears

Stupid Girls – Pink

Superwoman – Alicia Keys

Swan Dive – Ani DiFranco

The Pill – Loretta Lynn

This Woman’s Work – Kate Bush

Why Go – Pearl Jam

Woman in the Moon – Barbra Streisand

Women Should be a Priority – Sweet Honey and the Rock

You Don’t Own Me – Lesley Gore

You Oughta Know – Alanis Morisette

Your Revolution – Sidebar

Counseling and Psychotherapy Theory and Practice

Tips for Teaching Theories of Counseling and Psychotherapy

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[These tips are adapted from the online instructor’s manual for

Counseling and Psychotherapy Theories in Context and Practice by

John and Rita Sommers-Flanagan, John Wiley & Sons, 2012]

            At the University of Montana,  we teach theories in both large lecture sections and in smaller graduate seminars. Regardless of class size and venue, we find the following teaching strategies useful.

  1. Open the class with an engaging story about whichever theory, theorist, or approach you’ll be covering.
  2. Alternatively, open class with a quick reflection on what students recall from the previous class period.
  3. Then transition to a brief description or outline of what you intend to cover (generally we follow the outline of the chapter, but regularly make planned or spontaneous detours).
  4. Focus on historical context and biographical information linked to the theory/theorist. We use some of the powerful quotations available in the text and elsewhere for this and have the quotations on the powerpoint slides.
  5. Transition to theoretical principles.
  6. Approximately every 15-20 minutes we weave in one of the following teaching strategies
    1. A personal or professional anecdote about the theory or theorist (e.g., When I met William Glasser in the ACA Exhibition Hall)
    2. A short “turn to your table or neighbor” discussion question; we generally allow 3-5 minutes for these activities
    3. A short answer question posed to the entire class
    4. A video clip (this may include a youtube video or a more professional video clip demonstrating a therapy technique)
    5. A short interactive activity where students turn to each other and “try out” specific counseling or psychotherapy techniques (e.g., we have students do a 90 second “free association” with each other – see Section Two of the Instructor’s Manual for more interactive, in-class activities)
    6. A brief in-class demonstration of a technique with a class volunteer, followed by classroom debriefing and discussion
    7. A story about a specific therapy case that illustrates how the theoretical perspective is applied
    8. After reviewing the key theoretical principles, it’s time to focus on specific therapy process and specific therapy techniques associated with the theory. This is one place where we’re likely to do an in-class demonstration or a therapy video clip. However, our policy is to keep things moving by never going over 10 minutes of a demonstration or video without stopping the action and discussing student observations.
    9. After reviewing specific therapy process and techniques (including demonstrations), we move to briefly exploring the evidence-base or empirical support for the approach. We recognize that this is not a class that emphasizes research, but featuring a particular research study or reviewing meta-analytic data can help keep students oriented to the value and limits of research.
    10. Although we try to integrate ethics and diversity issues into as many parts of our lecture and class presentation as possible, at the very least we take time to focus on these issues toward the end of class. For example, we pose questions to the class like: (a) How do you think you could apply this approach with an Native American client, or (b) What are some of the common ethical issues that might arise when doing Gestalt therapy?
    11. At the end of each class we make a practice of asking students to do an informal homework assignment. For example, after the class on psychoanalytic theory and therapy we ask students to pay attention to the internal thoughts (or voice) in their head and think about whether this inner voice is speaking nicely to them (e.g., supportive ego type inner speech) or harshly (e.g., more like a negative internalized object or harsh superego/conscience). The purpose of these informal assignments is to help students not just gain intellectual knowledge, but to have them experience how the theoretical concepts might play out in their lives.

Perhaps the most important principle to teaching theories is to never let too much time pass without student-student or student-instructor interaction. The purpose of these interactions is to not simply keep the class moving and students engaged (although that’s important as well), but to consistently make counseling and psychotherapy theory and technique something that students are able to talk about and connect with their daily experiences.