Category Archives: Counseling and Psychotherapy Theory and Practice

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

Reformulating Clinical Depression: The Social-Psycho-Bio Model

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At a 2007 Mind and Life Conference at Emory University, I had the privilege of watching and listening as Charles Nemeroff, M.D., presented a professional paper to His Holiness the Dalai Lama. [As my older daughter would likely say, Dr. Nemeroff is a very fancy biological psychiatrist.] Nemeroff noted, with some authority, that we now know that one-third of all depressive disorders are genetically-based and two-thirds are environmentally-based. Following this statement, Nemeroff continued to discuss the trajectory of “depressive illness,” focusing, in particular, on findings linked to mice with early maternal deprivation and related findings regarding trauma and depression. His conclusion was that, for some individuals (and mice), the brain is changed by early childhood trauma, while for others, the brain seems unaffected. Interestingly, at that point in the conference the Dalai Lama interrupted and there were animated interactions between him and his interpreter. Finally, the interpreter directed a question to Nemeroff, stating something like, “His Holiness is wondering, if two-thirds of depression is caused by human experience and one-third is caused by genetics, but that humans who are genetically predisposed to depression have to have a trauma for the depression to be manifest, then wouldn’t it be true to say that all depression is caused by human experience?” After a brief silence, Nemeroff responded, “Yes. That would be true.”

Most of us have heard about the biopsychosocial model in contemporary medicine. Below I’ve included some information about its origin (this info is adapted from a 2009 Journal of Contemporary Psychotherapy Article; you can find the whole article here: http://www.coping.us/images/Sommers_Campbell_2009_EBP_for_Kids.pdf).

In his 1980 call to medicine, Engel (1980; 1997) encouraged adoption of a biopsychosocial model of health and illness. Despite this recommendation and the increased use of ‘biopsychosocial’ language among non-medical practitioners, medicine has demonstrated little movement toward embracing a biopsychosocial perspective (Alonso, 2004). To some extent, the Nemeroff-Dalai Lama interaction illustrates medical professionals’ tendencies to formulate mental health problems as disease states even when their own data are contradictory. At the Mind and Life Conference, Nemeroff continued to present his illness-based depression formulation even after conceding environmental causality of depression (Nemeroff, 2007).

Although we (Sommers-Flanagan & Campbell) generally advocate medicine’s biopsychosocial model, we see utility in a slightly more radical reconceptualization of depression–especially among youth. This belief rests upon knowledge about the etiology, course, and treatment of depression, equivocal data regarding antidepressant medication effectiveness, potential developmental and medical dangers associated with short- and long-term SSRI use, research on child development and trauma, and our own clinical experience (Sommers-Flanagan & Sommers-Flanagan, 1995a; Sommers-Flanagan & Sommers-Flanagan, 2007). In short, instead of a biopsychosocial model for understanding and treating youth depression, we believe a social-psychological-biological approach is more consistent with current scientific and clinical knowledge.

A Social-Psycho-Bio Model of Clinical Depression

All humans are born into pre-determined social and cultural settings, which directly influence emotional, psychological, social, and biological functioning and development (Christopher, 1996; Sue & Sue, 2013). Although space precludes complete articulation of the social-psycho-bio model, we describe the major components below.

Social-cultural components. Many cultural factors contribute to children’s emotional and psychological development. For example, in the United States, babies are often born to socially isolated mothers living in poverty. These mothers may also be depressed themselves and have little community and governmental support (Goosby, 2007; Knitzer, 2007). In contrast, more communal and supportive cultural settings place less of a parenting burden on individual mothers, thus possibly decreasing depression. It’s likely that different degrees of cultural support to families and children translate into different degrees of relative risk for depressive experiences in children.

Recent research affirms diverging cultural assumptions about depression etiology. Whereas South Asian immigrants viewed depressive symptoms as stemming from social and moral influences (Karasz, 2005), European Americans attributed depression to biological influences. These cultural formulations or expectations likely influence medication or psychotherapeutic efficacy. Although biomedical researchers emphasize genetic contributions to depression, an individual’s depressive predisposition may be strongly influenced by overarching cultural factors. Given Nemeroff’s admission that depression is rooted in human experience, it seems appropriate to us that depression formulations lead with social and cultural, rather than biological factors.

Early caretaker-child interactions. Early caretaker-baby interactions appear to stimulate depression development in very young children. The best example of this comes from studies of maternal depression, which demonstrate that mothers’ depressive behaviors influence their children’s own emotional suffering and other neurological changes (Ashman & Dawson, 2002). This evidence for a direct effect of caregiver behavior on children’s neural activity and possible brain development supports the social-psycho-bio model.

Child trauma. Garbarino’s (2001) statement, “Risk accumulates; opportunity ameliorates” (p. 362) suggests that repeated trauma in the absence of support or opportunity can deeply damage children. Trauma typically occurs within a social and cultural context, and without requisite support and opportunity, it can initiate cognitive, emotional, and social pathology. Sufficiently intense trauma may also produce lasting “psychic scars” (Terr, 1990). Additionally, early childhood trauma drains children and adults of meaningfulness (Garbarino, 2001). There is little doubt about the powerful contribution of trauma to the development of clinical depression and other mental disorders.

Psychological/cognitive development of depressive symptoms. Considerable evidence supports a cognitive model of depression in adults, and to some extent, in adolescents and children (Kazdin & Weisz, 2003). The pioneering work of Aaron Beck (1970) emphasizes that personal experiences lead individuals to acquire specific negative beliefs about themselves, the world, and the future (i.e., the cognitive triad). Although empirical support for the cognitive triad’s contributory and maintenance roles in depression is strong, these belief systems do not rise autonomously within the psyche. Instead, as Beck notes, these deeply ingrained beliefs are learned vis-à-vis interpersonal experiences.

The development of schemata or internal working models. Theorists spanning analytic, neoanalytic, cognitive, and attachment perspectives have proposed concepts that can be described as schemata or internal working models (Ainsworth, 1989; Glasser, 1998; Morehead, 2002; Young, Klosko, & Weishaar, 2003). Although each theoretical perspective articulates the concept somewhat differently, all involve development of a psychological pattern of repetitive automatic beliefs and expectations. These beliefs and expectations, which implicate the self, the world, and others (or objects), generate repetitive behaviors and affect. A cognitive schema or internal working model arises from early social interactions and may contribute to depression and other emotional and behavioral maladies. From a behavioral perspective, depressogenic working models involve early maladaptive reinforcement contingencies, which must be unlearned before one can acquire more adaptive behavior patterns.

Regardless of theoretical orientation, the internal working model concept forms the foundation of many psychological interventions. For example, it clearly underlies CBT and interpersonal therapy (IPT), two evidence-based practices for treating depression in youth (Kazdin & Weisz, 2003). Essentially, internal working models or schemata include internalized early experiences, and they constitute the “psycho” component of the social-psycho-bio model. When positive, adaptive, and healthy early experiences predominate, internalized working models buffer or immunize the individual against stress and trauma. When critical, negative, and maladaptive experiences predominate, schemata can predispose an individual to acute, chronic, or recurrent depressive episodes.

Neurological (brain-based) manifestations of depression. In addition to social, cognitive, emotional, and motivational experiences, current and recent research has identified cortical functioning correlates of depression. These correlates include neurochemical changes and neural activity, which can be observed via Positron Emission Tomography or functional Magnetic Resonance Imaging. Typically, brain imaging studies in animals, youth, and adults are presented as evidence of biomedical or biogenetic causal factors of depression. In the social-psycho-bio model described here, we suggest that neural changes are natural and inevitable correlates of internalized depressive life experiences. Because we are all biological organisms, observable neural changes associated with clinical depression should come as no surprise. It is important to note, however, that brain changes represent a physical phenomenon correlated with depression; these changes may or may not be causative.

Individuals with more extreme, recurrent, or chronic depressive experiences are perhaps more likely to evidence neurochemical states that add to or maintain depression. Again, we view this as a natural biological process. In some circumstances, this state might require a biological agent (or medication) to be used in combination with psychotherapy to facilitate depression recovery.

Our social-psycho-bio model advocacy does not exclude biomedical contributors to depression. Instead, it identifies biological manifestations as correlates of social and psychological dimensions of depression. This argument has been articulated before, but without much success. We attribute the failure of this view to the din of medication marketing and a cultural orientation toward quick fixes. In fact, we are all biological creatures with intricately interconnected brains characterized by dazzlingly complex electrochemical communication. The search for fMRI and PET scan differences between depressed and non-depressed individuals represents a logical and natural development in our understanding of depression as it exists within the whole person. Although neurochemical changes might maintain depression, it is not necessarily the case that neurochemical factors (or the vernacular ‘chemical imbalances’) initiate depressive processes. Indeed, these neurochemical changes are just as likely to be consequences of depressive conditions. Based on this depression re-formulation, we believe that it would be appropriate to initiate antidepressant medication treatment as an adjunctive approach if previously attempted experiential interventions, including exercise, dietary adjustments, and psychotherapy failed to achieve desired effectiveness. Further, conceptualizing neurochemical changes as depressive correlates rather than causes, lead us to agree with others who maintain that medication treatment should be considered a palliative and not curative treatment (Overholser, 2006).

[Again, please note that much of the preceding is adapted from a previously published article in the Journal of Contemporary Psychotherapy. The article was titled, “Psychotherapy and (or) Medications for Depression in Youth? An Evidence-Based Review with Recommendations for Treatment.” Citations are available in the original article.]

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Strategies for Working Effectively with Challenging Clients

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Working with clients who are reluctant or resistant to counseling can be very challenging . . . unless you use skills to help minimize resistance and maximize cooperation. The following is adapted from Chapter 12: Challenging Clients and Demanding Situations of the forthcoming 5th edition of Clinical Interviewing. Remember, these skills have to come from a foundation of therapist genuineness.

Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback

Clients sometimes begin interviews with expressions of hostility, anger, or resentment. If this is handled well, these clients may eventually open up and cooperate. The key is to refrain from lecturing, scolding, or retaliating when clients express hostility. Speaking from the consultation-liaison psychiatry perspective, Knesper (2007) noted: “Chastising and blaming the difficult patient for misbehavior seems only to make matters worse” (p. 246).

Instead, empathy, emotional validation, and concession are more effective responses. We often coach graduate students on how to use concession when power struggles emerge, especially when they’re working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). For example, if a young client opens a session with, “I’m not talking and you can’t make me,” we recommend responding with complete concession of power and control: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s need for power and control and concedes an initial victory in what the client might be viewing as a struggle for power.

Empathy and Emotional Validation

Empathic, emotionally validating statements are also important. If clients express anger at meeting with you, a reflection of feeling and/or feeling validation response can let them know you hear their emotional message loud and clear. In some cases, as in the following example, therapists might go beyond empathy and emotional validation and actually join clients with a parallel emotional response:

  • “Of course you feel angry about being here.”
  • “I don’t blame you for feeling pissed about having to see me.”
  • “I hear you saying you don’t trust me, which is totally normal. After all, I’m a stranger, and you shouldn’t trust me until you get to know me.”
  • “It pretty much sucks to have a judge require you to meet with me.”
  • “I know we’re being forced to meet, but we’re not being forced to have a bad time together.”

Radical Acceptance

Radical acceptance is a dialectical behavior therapy principle and technique based on person-centered theory (Linehan, 1993). It involves consciously accepting and actively welcoming any and all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). For example, we’ve had experiences where clients begin their sessions with angry statements about the evils of psychology or counseling:

Opening Client Volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.

Radical Acceptance Return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate psychologists but they just sit here and pretend to cooperate. So I really appreciate you telling me exactly what you’re thinking.

Radical acceptance can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. Our favorite version of this is the “Love reframe” (J. Sommers-Flanagan & Barr, 2005).

Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. So let’s just get this over with.

Therapist: I hear you saying this is bullshit. You must really love your daughter . . . to come here even when you think it’s a worthless waste of your time.

Client: (Softening) Yeah. I do love my daughter.

The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone, which turns the interview toward a more pleasant focus.

Genuine Feedback

Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings . . . pausing . . . and then following with honest feedback and a solution-focused question.

“I hear you saying you hate the idea of talking with me, and I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent]. You know, you’re in legal trouble. I’d like to try to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour or we can talk about how you might dig yourself out of this legal hole you’re in. I can go either way. What do you think . . . if we had a good meeting today, what would we accomplish?”

Think about how you can incorporate, empathy, emotional validation, concession, radical acceptance, and genuine feedback into your clinical practice. For more on this, check out the 5th edition of Clinical Interviewing.

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

A Summary Checklist of Strategies and Techniques for Managing Client Resistance

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One friend of mine who is a therapist has a very deep voice. Years ago, we were both seeing lots of boys who were often angry. These boys were also, no big surprise, resisting the advice and direction of authority figures, like parents and teachers. Several times I got a chance to work with young male clients who had “blown out” of therapy with my friend.

They described him as frightening. They said he would joke about having a “rack” in the back room in his office building and threaten to take them there if they wouldn’t talk. For young clients who got his sense of humor and who could see past his deep voice, his style worked very well. But for other youth, a kinder and gentler approach with less room for misinterpretation was needed.

In the following excerpt from Clinical Interviewing (5th edition), Rita and I are just finishing our discussion of why clients lie and resist counseling. Most of our thinking in this are is based on a combination of motivational interviewing and our own counseling and psychotherapy experiences-like the one described above. Following the end of our brief comments about lying and resistance, we include a summary table listing strategies and techniques for dealing with resistant clients that might be helpful to you. If you want more information about this, feel free to email me at john.sf@mso.umt.edu and I can send you an article or a chapter on working with resistant youth. Here’s the excerpt:

. . . . There are many reasons why clients lie, most involving some form of self-protection or the belief that they profit from lying. As a general rule (with exceptions), people tend to lie more if they feel the need to lie and tend to lie less when they experience trust. As a consequence, your goal is to build an alliance that includes enough trust to facilitate honesty. Confrontation of obvious or subtle lying behavior may be less productive than waiting for rapport and trust to build and for honest disclosure to flow more naturally. This perspective or stance can be a relief; when in the role of therapist (and not judge) facts are usually less important than feelings. To summarize, resistance, or whatever we choose to call it, is a natural part of the change process. In fact, research suggests that client resistance is an opportunity for deeper work. When resistance is worked through, the likelihood for positive outcomes is increased (Mahalik, 2002).

In the end, it’s helpful to remember that resistance emanates from the very center of a person and is part of the force that gives people stability and predictability in their interactions with others. Resistance exists because change and pain are often frightening and more difficult to face than retaining the old ways of being, even when the old ways are maladaptive. Finally, with culturally or developmentally different clients, resistance may actually be caused when the therapist refuses or fails to make culturally or developmentally sensitive modifications in his or her approach (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). Table 12.1 includes a summary of strategies and techniques for managing resistance.

 

Table 12.1 Summary Checklist of Strategies and Techniques for Managing Resistance
____  1. Adopt an attitude of acceptance and understanding because developing a therapeutic alliance is almost always a higher priority than confrontation.
____  2. Recognize that clients will feel some ambivalence about working toward and achieving positive change.
____  3. Resist your impulses to teach, preach, and persuade clients to make “healthy” decisions.
____  4. In the beginning and throughout the session, ask open-ended questions that are linked to potential positive goals.
____  5. Look for positive goals that are underlying your clients emotional pain and discouragement—and then help your client be the one who articulates those goals.
____  6. Use simple reflection to reduce clients’ needs to exhibit resistance.
____   7. Use concession “You’re right. I can’t make you talk with me” to affirm to clients that they’re in control of what they say to you.
____  8. Use amplified reflection to encourage clients to discuss the healthier side of their ambivalence.
____  9. Use emotional validation when clients are angry or hostile.
____ 10. Use radical acceptance to compliment clients for their openness—even though the openness may be aggressive or disturbing.
____ 11. Reframe client hostility and negativity into more positive impulses whenever possible.
____ 12. Provide genuine feedback related to your concerns to your clients.
____ 13. Use paradox carefully to respectfully come up alongside clients’ resistance.
____ 14. If you’re concerned about truthfulness, get signed consent and then interview a significant other to help you get an accurate story.
____ 15. When clients ask “Do you believe me?” use a response that will encourage more disclosure, like, “I’m not here to judge the truth, but just to listen and try to be of help.”
____ 16. Remember (and be glad) that you’re a mental health professional and not a judge.

From Clinical Interviewing (5th edition). See: http://www.wiley.com/WileyCDA/Section/id-302475.html?query=John+Sommers-Flanagan

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

DSM-5 and the Universal Diagnostic Exclusion Criteria

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Sometimes, even when someone appears to meet all the diagnostic criteria for a mental disorder, assigning a psychiatric diagnosis is still not the right thing to do.

In the following excerpt from the forthcoming 5th edition of Clinical Interviewing, we offer an example of when and why psychiatric diagnosis is inappropriate (see: http://lp.wileypub.com/SommersFlanagan/). We refer to this as the “Three-Dimensional Universal Exclusion Criterion” which is our highly esoteric way of saying, “Whoa on psychiatric diagnosis until you’ve checked to see if there’s an alternative explanation for the observed behaviors!”

Multicultural Highlight 6.2

The Three-Dimensional Universal Exclusion Criterion: Is the Behavior Rationally or Culturally Justifiable or Caused by a Medical Condition?

Let’s say you meet with a client for an initial interview. During the interview the client describes an unusual belief (e.g., she believes she is possessed because someone has given her the “evil eye”). This belief is clearly dysfunctional or maladaptive because it has caused her to stop going out of her house due to fears that an evil spirit will overtake her and she will lose control in public. She also acknowledges substantial distress and her staying-at-home-and-being-anxious behavior is disturbing her family. In this case it appears you’ve got a solid diagnostic trifecta—her belief-behavior is (a) maladaptive, (b) distressing, and (c) disturbing to others. How could you conclude anything other than that she’s suffering from a psychiatric disorder?

This situation illustrates why diagnosis (see Chapter 10) is a fascinating part of mental health work. In fact, if the client has a rational justification for her belief-behavior . . . or if there’s a reasonable cultural explanation . . . or if the belief-behavior is caused by a medical condition—then it would be inappropriate to conclude that she has a mental disorder. One source of support for a universal exclusion criterion is the DSM-5. It includes the statement: “The level of severity and meaning of the distressing experiences should be assessed in relation to the norms of the individual’s cultural reference groups” (American Psychiatric Association, 2013, p. 750).

To explore our three-dimensional “universal” exclusion principle in greater depth, partner up with one or more classmates and discuss the following questions:

Can you think of any rational explanations for the client’s belief-behavior?

Can you think of any reasonable cultural explanations for the client’s belief-behavior?

Can you think of any underlying medical conditions that might explain her belief-behavior?

After you’ve finished discussing the preceding questions, see how many new examples you can think of where a client presents with symptoms that are (a) dysfunctional/maladaptive, (b) distressing, and (c) disturbing to others. Then discuss potential rational explanations, cultural explanations, and medical conditions that could produce the symptoms (e.g., you could even use something as simple as major depressive symptoms and explore how rational, cultural, or medical explanations might account for the symptoms, thereby causing you to defer the diagnosis.

 

Counseling and Psychotherapy Theory and Practice, Therapy with Adolescents

Tough Kids, Cool Counseling: Dealing with “Resistance” – Part 1

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Working with challenging, tough, or naturally resistant youth is one of the most difficult situations a counselor or psychotherapist can face. In this excerpt from chapter 3 of “Tough Kids, Cool Counseling” (published by ACA, 2007), we begin discussing strategies for dealing with this difficult situation. Here’s a link to the Amazon page for this book: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_2?ie=UTF8&qid=1370790501&sr=1-2

Chapter 3

Resistance Busters: Quick Solutions and Longer-Term Strategies

As noted in preceding chapters, adolescents are well-known for their general distrust of adults and their striving for autonomy (Erikson, 1963; Saginak, 2003). Despite this distrust and independence-striving, in most cases, by using the strategies and techniques discussed in Chapter 2, counselors can manage resistance and initiate therapy with clients and their parents. However, upon entering a counseling situation, some young people will display extreme, provocative, or puzzling resistance behaviors that require more specialized approaches (Amatea, 1988; Richardson, 2001).

Imagine the following scenario:

You’re an intern scheduled to meet with a 15-year-old girl referred to a community clinic from a local group home. You’ve been in graduate school for about 18 months and so you’re not completely naïve, but because you’re only 23 years old yourself (and you went through a fair bit of emotional turmoil during your teen years), you’re especially excited about the opportunity to help a teenager who is obviously in a challenging life situation.

When you meet your client, Maya, in the waiting room, your enthusiasm begins to wane. Her jet-black and pink fringed hair hangs over her eyes and she reeks of cigarette smoke. When you greet her, she sneers, causing her lip-ring to flip upward. Her eyes (or at least what you can see of them) roll back as if she is disgusted at the sight of you.

Her first spoken words to you are: “This is a fucking waste of my time.”

You’re not sure what to say and so the Carl Rogers voice inside of you says gently, “It sounds like you’re not very happy to be here.”

Maya’s response is to slip into a stony silence, a silence only occasionally broken with deep dramatic sighs. Eventually, when she finally speaks again, she says, “Oh my fucking God. And you’re supposed to help me?  That’s a joke.”

Some teenagers have a special talent for destroying their counselor’s confidence. Not surprisingly, our graduate students, when facing a client like Maya for the first time, are often stunned. They complain of having a blank-mind and not knowing what to say. Other common reactions to the Maya-prototype include overwhelming feelings of inadequacy (usually accompanied by anxiety) or strong impulses to retaliate with anger.

This chapter focuses on strategies and techniques for dealing with some of the most provocative behaviors you’re likely to see in counseling situations. Our belief is that counselors should prepare, plan, and look forward to aggressive resistance from teenage clients or students. Again, we emphasize that aggressive resistance is best viewed as a coping style brought into the counseling situation and directed towards anyone in authority—in Sullivan’s terms, a parataxic distortion (Sullivan, 1953). Therefore, when working with challenging youth, keep one key fact clearly in mind: Your client’s insults, disgust, and aggressive behavior, although aimed at you, have virtually nothing to do with you. There’s no point in taking your client’s comments personally, and in fact, if you can side-step the onslaught, it will provide you with all sorts of important diagnostic and clinical information about your client’s pain and defenses.

Getting Your Buttons Pushed

Despite our great advice about not taking your client’s degrading comments personally, in the real world, we all get our buttons pushed sometimes. A graphic example of counselor over-reaction to provocative client behavior was captured in the feature film, Good Will Hunting (Van Sant, 1997).

As a fan of counseling, you may recall the scene. The main character, Will, played by Matt Damon, is an extremely intelligent but emotionally disturbed young man with mathematical genius. His would-be mentor, in an effort to help Will fulfill his potential, sends him to several different counselors, none of whom are able to help Will. Finally, Will ends up in the office of Sean McGuire, played by Robin Williams.

During his initial session with McGuire, Will is his provocative and nasty self. He eventually, either accidentally, or via great intuition, begins insulting McGuire’s deceased wife and because he is still unresolved about his wife’s premature death, McGuire gets his emotional buttons pushed. The result: the counselor grabs Will around the neck and slams him up against the wall. Of course, McGuire also decides to take on Will as a client and successfully helps Will move forward in his life.

We would like to emphasize two key points related to this excellent example of resistance and countertransference from Good Will Hunting. First, be aware of your emotional buttons, seeking the support and counseling you need to be an effective and ethical counselor. Second, no matter how provocative your young clients may act, avoid using Robin Williams’s “Choking the client” technique.  It may play well in Hollywood, but physical contact with resistant, aggressive, and/or angry clients is highly ill-advised.

If you find you’re having your emotional buttons pushed occasionally by teenage clients or students, consider yourself normal. On the other hand, if the button pushing begins to cause you to contemplate acting on destructive impulses, it’s time to get therapy for yourself, and/or support from a collegial supervision group. Many psychoanalytically-oriented writers have warned about the powerful regressive countransference impulses that young clients can ignite in their counselors (Dass-Brailsford, 2003; Horne, 2001).

Pause for Reflection: How do you usually respond when you get your buttons pushed by someone? Do you instantly feel angry? Or, are you more likely to scrutinize yourself and decide that you really are just an inadequate and worthless piece of furniture? Of course, there’s no “right” response to these questions. The best guideline is to continually work at looking at yourself and your reactions to clients so that you are consistently cultivating your self-awareness.

[End of Pause for Reflection]

To work ethically and professionally with provocative clients requires general skill, personal insight, and a particular knowledge base that includes a range of potentially constructive automatic or formula responses.

Counseling and Psychotherapy Theory and Practice

Sara Pranks John During the Theories Video Production

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When the psychoanalytically-oriented demo session begins and Sara starts talking about a repeating dream she had that involved some ferns, a cave, and a pickle, he quickly realizes he’s in trouble. Somehow an earlier version of this video was cut short on this website and so I’m trying to post this again.

Boys and Men, Counseling and Psychotherapy Theory and Practice, Therapy with Adolescents

A Call Out to Anyone with an Opinion on How to Raise Emotionally Healthy Boys who are Capable of Excellent Intimate Relationships

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Hello Blog Followers:

Over the past twenty years I’ve grown increasingly concerned about the developmental challenges and pitfalls that boys and young men face. My concerns arise partly due to my professional work with young males and their parents and partly due to recent news about the “Boy crisis” in the U.S.

For a long time I’ve wanted to write a book that would be helpful to young men and to the parents, teachers, coaches, and others who care about them and their development. I finally have some time for this project and would like to invite people to contribute thoughts and stories that will help me shape and enrich what I want to say.

This is not a research project. I have no intent to generalize any findings or build a theory. The purpose is journalistic in that I intend to listen to individuals who share thoughts and stories with me and then report some of this information within the frame I’ve already established for the book.

I’m looking for people who might want to share a story, an experience, or an opinion about boys and their development, particularly their sexual development. If you’re interested, here’s the plan:

  1. Email me at drjohnsproject@gmail.com; You’re welcome to do this anonymously.
  2. In response, I’ll send you an email with about 10 questions, some general and some specific.
  3. After you receive the email with the questions, you can choose to email me back (or not). And you can respond to any or all of the questions (or you can even make up your own questions that you feel are important). I won’t quote anyone without permission.

Thanks very much for considering sharing your thoughts or stories. I appreciate your time. I hope this project helps boys and their caretakers overcome some of the more destructive and misguided messages about maleness in our current culture. Boys deserve our help as they strive to become productive, mature, and compassionate men.

Sincerely,

John Sommers-Flanagan, Ph.D.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Recommendations for Developing and Using a Positive Working Alliance

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Although Freud started the conversation, he might not recognize contemporary models of the working alliance. This is because Freud advocated analyst emotional distance and a detached psychoanalytic stance, whereas today’s working alliance involves therapists initiating a process of collaborative engagement with clients.

Therapists who want to develop a positive working alliance (and that should include all therapists) will integrate strategies for doing so during initial interviews and beyond. Based on Bordin’s (1979) model, alliance-building strategies would focus on (a) collaborative goal setting; (b) engaging clients on mutual therapy-related tasks; and (c) development of a positive emotional bond. Additionally, feedback monitoring within clinical interviews is recommended.

Initial interviews and early sessions appear especially important to developing a working alliance. Many clients who enter your office will be naïve about what will be happening in their work with you. This makes including role inductions or explanations of how you work with clients essential. Here’s an example from a cognitive-behavioral perspective:

For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)

Asking direct questions about what clients want from counseling and then listening to them and integrating that information into your treatment plan is also important: In cognitive therapy this is often referred to as making a problem list (J. Beck, 2011).

Therapist:    What brings you to counseling and how can I be of help?

Client:         I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.

Therapist:    Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we write, “Find ways to help you start feeling more up?”

Client:         Sounds good to me.

Engaging in a collaborative goal-setting process—and not proceeding with therapy tasks until it’s clear that mutual goals (even temporary mutual goals) have been established

Therapist:    So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?

Client:         Absolutely yes. If we can climb those three mountains it will be great.

Soliciting feedback from clients during the initial session and ongoing in an effort to monitor the quality and direction of the working alliance. Although there are a number of instruments you can use for this, you can also just ask directly:

We’ve been talking for 20 minutes now and so I just want to check in with you on how you’re feeling about talking with my today. How are you doing with this process?

Making sure you’re able to respond to client anger or hostility without becoming defensive or launching a counterattack is essential to establishing and maintaining a positive working relationship. In our work with challenging young adults, we apply Linehan’s (1993) “radical acceptance” concept. For example, an initial session with an 18-year-old male started like this:

Therapist:    I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:         You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).

Therapist:    Thanks for telling me about that. I definitely want to avoid getting punched in the nose. And so if I accidentally say anything that offends you I hope you’ll tell me, and I’ll try my best to stop.

In this case the therapist accepted the client’s aggressive message and tried to transform it into a working concept in the session.

Having specific therapy tasks (no matter your theoretical orientation) that fit well with the mutually identified therapy goals. For example, if illuminating unconscious processes is a mutually identified goal, then using free association can be a task that makes sense to the client. On the other hand, if you’ve agreed to work toward greater self-acceptance and greater acceptance of frustrating people in the client’s life, then engaging in intermittent mindfulness tasks will feel like a reasonable approach.

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Why Therapists Should Never Say, “I know how you feel”

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The following excerpt is adapted from the fifth edition of the text, Clinical Interviewing (John Wiley & Sons, 6th edition forthcoming in October).

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Many writers have tried operationalizing Carl Rogers’s core conditions. However, efforts to transform person-centered therapy core conditions into specific behavioral skills always seem to fall short. As Natalie Rogers (J. Sommers-Flanagan, 2007) emphasized, trying to translate the core conditions into concrete behaviors is usually a sign that the writer or therapist simply doesn’t understand person-centered principles.

This lack of understanding occurs principally because core Rogerian attitudes are attitudes, not behaviors. This is a basic conceptual principle that has proven difficult to understand—perhaps especially for behaviorists. The point Rogers was making then (in the 1950s), and that still holds today, is that therapists should enter the consulting room with (a) deep belief in the potential of the client; (b) sincere desire to be open, honest, and authentic; (c) palpable respect for the individual self of the client; and (d) a gentle focus on the client’s inner thoughts, feelings, and perceptions. Further complicating this process is the fact that the therapist must rely primarily on indirectly communicating these attitudes because efforts to directly communicate trust, congruence, unconditional positive regard, and empathic understanding is nearly always contradictory to each of the attitudes.

A counselor educator friend of ours, Kurt Kraus, articulated why trying to directly communicate understanding is problematic. He wrote:

When a supervisee errantly says, “I know how you feel” in response to a client’s disclosure, I twitch and contort. I believe that one of the great gifts of multicultural awareness is for me accepting the limitations to the felt-experience of empathy. I can only imagine how another feels, and sometimes the reach of my experience is so short as to only approximate what another feels. This is a good thing to learn. I’ll upright myself in my chair and say, “I used to think that I knew how others felt too. May I teach you a lesson that has served me well?” (J. Sommers-Flanagan & Sommers-Flanagan, 2012) (p. 146)

Kraus’s lesson is an excellent one for all of us. The phrases, “I know how you feel” and “I understand” should be stricken from the vocabulary of counselors and psychotherapists.

Counseling and Psychotherapy Theory and Practice, Parenting

Practicing Cultural Humility with Parents

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Alfred Adler (1958) claimed that every child is born into a new and different family. He believed that with every additional member, family dynamics automatically shift and therefore a new family is born (J. Sommers-Flanagan & Sommers-Flanagan, 2004a). If we extend Adler’s thinking into the cultural domain, it might be appropriate to conclude: “Every family is born into a new and different culture.”

[This is an excerpt from “How to Listen so Parents will Talk and Talk so Parents will Listen.” It’s at: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_5?ie=UTF8&qid=1369460232&sr=1-5%5D

To be sure, culture is not a static condition; it’s a malleable and powerfully influential force in the lives of parents and children. Vargas (2004) stated,

“Culture is not about outcome. Culture is an ever-changing process.  One cannot get a firm grip of it just as one cannot get a good grasp of water.  As an educator, what I try to do is to teach about the process of culture—how we will never obtain enough cultural content, how important it is to understand the cultural context in which we are working, and how crucial it is to understand our role in the interactions with the people with whom we want to work or the communities in which we seek to intervene. . . .  I do not want to enter the intervention arena (whether in family therapy or in implementing a community-based intervention) as an “expert” who has the answers and knows what needs to be done.  I am not a conquistador, intent on supplanting my culture on others.  I have a certain expertise that, when connected with the knowledge and experience of my clients, can be helpful and meaningful to my clients.” (p. 429)

In part, Vargas was making the point that it’s more important for professionals to practice cultural humility than it is to view ourselves as culturally competent.

A Cultural Dialectic

All professionals should strive to be culturally sensitive and humble, seeking to respect and prize human diversity for the richness, variety, and surprises it brings to life.  But while embracing culture, it’s important to acknowledge that there’s no perfect culture, and sometimes cultural practices need to change or evolve for the sake of a given child, parent, or family.  Therefore, although we value divergent cultural perspectives, it’s also reasonable  to question whether specific cultural beliefs and rituals are useful or healthy to individuals, families, and communities. This is a cultural dialectic—similar to the radical acceptance dialectic discussed in Chapter 1.

When working with parents, it’s the professional’s job to do the cultural accepting and the parents’ job to do the cultural questioning. You should accept the parents’ cultural background, heritage, and parenting practices. However, if in the process of examining cultural influences on parenting, parents take the lead in questioning their culturally influenced parenting practices, you can and should remain open to helping parents push against cultural forces to make positive changes. For example, parents may want to discuss any of the following topics with you:

  • Whether or not to have their infant son circumcised
  • Their daughter’s body-image issues as they relate to American cultural values toward thinness
  • Whether it’s acceptable for their Muslim daughter to attend school or pursue higher education
  • Traditional Native American values and their children’s potential tobacco use

Helping parents determine whether their own cultural values clash with individual and/or family well-being is a delicate and potentially explosive process.  The challenge is to remain relatively neutral while helping parents evaluate cultural practices using their own parent-child-family health and well-being standards.

Case: Tobacco, Culture, and Addiction

Parent: I’m worried about my son and whether he’s started smoking. I use tobacco, in traditional Indian ceremonies, but I usually end up smoking more than I want to, and I see it as a bad habit, too. I’m not sure how to approach this with him because I don’t want to be a hypocrite.

Consultant: Tell me some ideas you’ve had, from your cultural perspective, about how to get the message you want to get to your son.

Parent: I want him to know that tobacco use should beceremonial or sacred, even though I use it more often than that. I know regular smoking is very unhealthy and so I don’t want him to have it as a habit, but I don’t know how to tell him that.

Consultant: If you think about someone from your tribe whom you really respect, how do you think that person would handle it?

Parent: In my tribe it’s really important to respect your elders. I’m my son’s mother and he should respect me, but you know how that goes. Maybe if I asked someone else, someone older and with even more respect than me, maybe that would help.

Consultant: Whom would you pick to help you talk with your son about this?

Parent: My older brother, his uncle, is pretty high up in the Tribal Government and maybe I could ask him to tell my son it would be better not to smoke, even though lots of Indian people smoke.

Consultant: Do you think your brother would be willing to give your son that message?

Parent: Yes. He’s traditional in some ways, but he’s very much against all smoking and drinking.

Consultant: You and your brother are both right about the dangers of regular tobacco use. As I imagine this discussion, I can see the two of you having a big impact on your son. But I guess there’s also the issue of your smoking and your son’s knowledge of that. Can you have your brother talk about that with your son, too? Or maybe both of you should do this together. How do you think this might work best?

In this case example, for the most part, the consultant is remaining neutral and respectful of the parent’s cultural traditions and yet, at the same time, helping her explore how to get her son a strong and clear message about not smoking tobacco.

Following the Parents’ Lead in Cultural Identity and Cultural Understanding

For most of us, culture is so deeply woven into our lives that it travels below awareness. From time to time we may glimpse it and wonder how it came to be that we choose to engage in specific cultural behaviors, such as:

  • Sitting on the couch with our children watching The Simpsons
  • Getting eggs from the store rather than directly from backyard chickens
  • Going to church on Palm Sunday where a processional, complete with a donkey, waits quietly in the sanctuary
  • Deferring to one’s husband
  • Expecting our oldest son to take care of us
  • Gathering with friends to overeat and watch the Super Bowl
  • Wearing a yarmulke, burkha, or other garments or pieces of cloth to cover our bodies or heads

Culture carries with it many questions, answers, and mysteries. As you can see from the preceding list, culture is ubiquitous; it’s impossible to escape its influence. It’s also impossible to accurately judge someone else’s cultural identity on the basis of physical appearance or initial impressions (Hays, 2008).

When working with parents, you shouldn’t assume parents’ cultural attitudes and experiences in advance. This is true no matter how similar or dissimilar to you the parents appear.  It’s best to begin with a clearly stated attitude of openness and then follow the parents’ lead.

Consultant: So, you grew up in Malawi?

Parent: Yes. I came to the United States when I was twenty-four.

Consultant: I don’t know how much of your Malawi tradition influences your parenting and so I hope it will be okay with you if, on occasion, I ask you about that.

Parent:  That’s no problem at all.

Consultant: And, as we talk, I hope you’ll feel free to tell me about anything that comes up or seems important about your particular cultural approach to parenting.

Parent: Yes. I’m comfortable with that.

Whether the parent is Laotian, Belizean, Argentine, French Canadian, or from any other cultural tradition, you should remain open to his or her particular and potentially diverse parenting approaches. However, you should also be open to helping parents question whether their own approaches to parenting are bringing them the results they desire. This is your professional duty. Again, the basic principle is to follow the parents’ lead in questioning cultural parenting practices and not become a cultural conquistador who tells all parents the one right way to be a parent.