Category Archives: Counseling and Psychotherapy Theory and Practice

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.

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

Your Life is Now: Trapper Creek Reflections

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The Road

Note: This is a re-post. I had a chance to drive to Trapper this past week with one of our doc students and I was reminded of the powerful life experiences that happen at Trapper Creek Job Corps.

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Sometimes on Thursday or Fridays I drive from Missoula to Trapper Creek Job Corps. Then I drive back the same day. It’s a 140 mile round trip. Sometimes I have interns with me. The company makes the miles go by more quickly. Sometimes the interns are very nervous sitting next to me for the whole drive and consequently compete to see who gets the back seat. This makes me wonder if maybe I shouldn’t quiz them about theories of counseling and psychotherapy as we drive there together. Although I wonder about this . . . I haven’t changed my behavior. Maybe this means I’m trying to scare them all into the back seat.

This week I was on my own. When this is the case I usually begin wondering why the heck I drive all these miles. Of course, I get paid to go to Trapper Creek. That’s one answer I give to myself. But I keep wondering anyway. It’s a long day, usually 11 or 12 hours. And when I’m about halfway there, 45 minutes into dodging deer with 45 more minutes to deal with Bitterroot drivers, I begin planning my retirement from Trapper Creek.

This is my 10th year (2013). I know the road and I know the deer and I know the Bitterroot drivers, who, in an apparent show of independence, nearly always drive either 10 mph under or 10 mph over the speed limit.

Today my retirement planning ended shortly after arriving at Trapper Creek. There were three straight appointments scheduled for me: three straight chances to do something more than talk about how to do psychological assessment and psychotherapy. And then a chance to observe and give feedback to the nursing staff and a chance to offer my unsolicited opinion to the physician on how to deal with an ingrown toenail and then a fourth student to see and a staff consultation and a meeting and a quick hello to our three University of Montana school counseling interns and wild typing of reports and poof . . . the day is over without a moment to ponder life or reflect on retirement.

The drive back to Missoula is nearly always better. There are stories to tell, opportunities to second guess myself, and unrealistic hopes and fantasies about having possibly helped someone. The miles melt away.

[The following stories are vague and distorted to preserve anonymity]

Today, with no interns for company my buddy John Cougar Mellencamp joined me on the drive back. We decided to sing together. We sang the same song so many times we lost count.

Your Life is Now

This is your time . . . to do what you will do

The first two young women were graduating from Trapper and moving on to advanced Job Corps training. They needed brief clinical interviews and mental status exams. These two hard working and delightful young women are at Trapper because they’ve experienced poverty and want to improve their lives.

Your life is now

One had a history of having been diagnosed with two severe mental disorders. Before coming to Trapper she’d been on two very powerful psychotropic medications. Funny thing: At Trapper she attained a very high level of functioning without medications . . . for nine straight months!

Your life is now

She had many “citations” for positive behavior. The staff love her. There was no shred of evidence that she had a mental disorder. So I just told her so. She grinned, looked at me, and said, “I guess that’s pretty good news.” Yep, pretty good news.

Your life is now

The second young woman was equally impressive.

In this undiscovered moment

But my last appointment, a young man with a history of trauma, really made my day.

We had visited two weeks previously and had made a plan to try some EMDR for his troubling trauma symptoms. He was eager and right on time. We talked briefly to warm up. He chose a memory. We went through various rating procedures included in the EMDR protocol.

Lift your head up above the crowd

We did several sets of eye movements. I did my usual wandering in and out of the “proper” EMDR protocol. After 10 minutes, we stopped and I asked him to reflect on his experience. He turned his head back and forth and said, “My neck doesn’t hurt anymore.”

We could shake this world

Then he smiled and said, “I feel like I can breathe again.” And then, “I wish I’d known about this ten years ago.”

If you would only show us how

Thank you Trapper Creek

Thank you fine young women and men

Thank you nurses and doctor and interns and staff

Thank you deer and Bitterroot drivers

Thank you for showing me how to shake this world and make a difference.

 Your life is now

Counseling and Psychotherapy Theory and Practice, Parenting

Building a Therapeutic Relationship with Parents: Part II – Using Radical Acceptance

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Building a Therapeutic Relationship with Parents: Part II – Using Radical Acceptance

Radical acceptance is a central therapeutic attitude held by practitioners who work effectively with parents. Radical acceptance is both an attitude and a clinical technique. This concept was originally articulated by Marsha Linehan (1993) and is a foundational component of dialectical behavior therapy. It involves a particular attitude that builds on Carl Rogers’s core therapeutic condition of unconditional positive regard as well as Eastern (Buddhist) philosophy.

Radical acceptance enables helping professionals to approach each client or parent with an overarching, pervasive dialectic belief, which we translate as, “I completely accept you just as you are and I am committed to helping you change for the better.” When working with parents, consultants strive to simultaneously hold both of these beliefs or attitudes. On the surface, these attitudes may seem contradictory, thus the term dialectic. At a deeper level, in a helping relationship, each attitude is necessary to complete the other.

As a technique, radical acceptance serves two main functions. First, it can help you refrain from expressing negative personal reactions to statements by parents that inadvertently push your buttons (we’ll focus more on button-pushing in Chapter 2). If you hear a statement that pushes an emotional button for you, having a radical acceptance attitude would help remind you that your job is to fully accept the person in the room with you—as is. In this situation, you don’t have to say anything as you simply quiet your roiling reactions. You can just be present and nonreactive.

Second, beyond momentary silence, radical acceptance allows parenting professionals to actively embrace whatever attitudes or beliefs parents bring into the consulting room. As we’ve stated previously (J. Sommers-Flanagan & Sommers-Flanagan, 2007):

The generic version or statement of radical acceptance is to graciously welcome even the most absurd or offensive . . . [parent] . . . statements with a response like, “I’m very glad you brought that [topic] up.” (p. 275)

Radical acceptance is especially warranted when parents say something you find disagreeable. This may include racist, sexist, or insensitive comments. For example:

Parent: I believe in limiting my children’s exposure to gay people. Parents need to keep children away from evil influences.

Consultant: Thanks for sharing your perspective with me. I’m glad you brought up your worries about this. Some parents have similar beliefs but won’t say them in here. So I especially appreciate you being honest with me about your beliefs. [Adapted from Sommers-Flanagan & Sommers-Flanagan, 2007, p. 276.]

Rest assured, radical acceptance does not mean agreeing with the content of whatever parents say. Instead, it means moving beyond feeling threatened, angry, or judgmental about parents’ comments and authentically welcoming whatever comes up during the session. The main purpose of welcoming disagreeable or challenging parent comments is to communicate your commitment to openness. If you don’t communicate and value openness by welcoming all remarks, parents or caregivers may never admit their core underlying beliefs. And if parents cover up their true beliefs—especially disagreeable or embarrassing beliefs—there will be no opportunity for insight or change because the underlying beliefs will never be exposed to the light of personal and professional inspection.

Similar to person-centered therapy, one key to using radical acceptance effectively is genuineness or congruence. This means you should never falsely welcome parents’ racist, sexist, insensitive, or outrageous comments. Instead, you should welcome such comments only if you really believe that hearing them is a good thing that can benefit the counseling or consultation process.

Radical acceptance also involves letting go of the immediate need to teach parents a new and better way. We must confess that we haven’t always maintained an attitude of radical acceptance ourselves. During one memorable session, upon hearing the classic line, “I got spanked and I turned out just fine!” John, being in an impatient and surly mood, barely managed to suppress an extremely destructive impulse (he wanted to say, “Are you really so sure you turned out fine?”). Nevertheless, a judgmental and dismissive comment still slipped out and he said: “I can’t tell you how many times I’ve heard parents say what you just said.” Not surprisingly, that particular session didn’t proceed with the spirit of empathy, acceptance, and collaboration we generally recommend.

This leads us to some obvious advice: Although you cannot be radically accepting all the time, you should always avoid radical judgment. There’s no need to test the “How about I treat parents in a judgmental, dismissive manner?” technique. Outcomes associated with judgmental and disrespectful counselor behavior are quite undesirable.

Stay Tuned for Part III on Building a Therapeutic Relationship with Parents tomorrow.