Category Archives: Counseling and Psychotherapy Theory and Practice

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.

Counseling and Psychotherapy Theory and Practice, Parenting

Building a Therapeutic Relationship with Parents: Part I

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Every parent is unique. But as a group, most parents have similar interests and goals. What this means for consultants and counselors and psychotherapists is that parents constitutea unique population and therefore to work effectively with parents requires a specifically tailored treatment approach and training in how to provide educational and therapeutic services for parents.

The following is an adapted excerpt from the book, “How to Listen so Parents will Talk and Talk so Parents will listen. For more info, go to: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_4?ie=UTF8&qid=1366501670&sr=1-4

To work effectively with parents, consultants or practitioners should use an approach that, similar to person-centered therapy, is characterized by three core attitudes: (1) empathic understanding; (2) radical acceptance; and (3) collaboration.

Empathy for Parents and Parenting

As is well-known, empathic understanding is one of the three core conditions for psychotherapy originally identified by Carl Rogers (1942; 1961; 1980). Over the years, research has left no doubt that therapist empathy facilitates positive therapy outcomes (Goldfried, 2007; Greenberg, Watson, Elliot, & Bohart, 2001; Mullis & Edwards, 2001). As applied to parents, empathy involves:

The therapist’s ability and willingness to understand the parent’s thoughts, feelings, and struggles from the parent’s point of view and an ability to see, more or less completely, through the parent’s eyes and adopt the parent’s frame of reference . . . . It means entering the private perceptual world of a parent. (adapted from Rogers, 1980, pp. 85, 142)

When working with parents, counselors, psychologists, and other human services professionals must learn to sensitively enter into the parent’s unique perceptual world. The practitioner needs to demonstrate empathy and sensitivity for specific parenting challenges. A person-centered perspective also implies that professionals who work with parents show empathy for the barrage of criticism, scrutiny, and associated insecurity that parents experience due to their exposure to social and media sources. Brazelton and Sparrow (2006) capture one way in which socially driven parental insecurity can manifest itself:

When Mrs. McCormick held Tim in her lap at the playground, she sat alone on a bench across from the other mothers as if she were ashamed of Tim’s clinging. She knew that if she sat by other mothers, they would all give her advice: “Just put him down and let him cry—he’ll get over it.” “MY little girl was just like that before she finally got used to other kids.” “Get him a play date. He can learn about other children that way.” (p. 8)

This example illustrates how parents anticipate criticism and work hard to avoid it. If you’ve been a parent or you work with parents, you know how easy it is for them to feel defensive about their children’s behaviors and their parenting choices. This is partly because, like Mrs. McCormick, they’re unable to measure up to narrowly defined parenting standards and cannot face the cascade of criticism or advice they’re likely to receive when their child doesn’t behave perfectly in social settings. To provide an optimally empathic environment, practitioners should have and show empathy or attunement with parents’ sensitivity to perceived or actual criticism and counter this sensitivity by amplifying their support and acceptance (we’ll cover therapeutic methods for amplifying support and acceptance in greater detail in Chapter 4).

Similar to the empathic attitude associated with person-centered therapy, it’s crucial for professionals who work with parents to hold the attitude that parenting is naturally difficult and that making mistakes or having a child who publicly misbehaves is nothing to feel shameful about. By maintaining this attitude, practitioners provide a nonjudgmental and empathic space for parents to explore their personal doubts and fears. This is the way the theory works: By being nonjudgmental, compassionate, and openly supportive, parenting professionals provide an environment free from societal conditions of worth, which then stimulates parents to become more open and collaborative when examining their weaknesses with a trusted professional.

Part II of this three part blog post continues tomorrow.

Counseling and Psychotherapy Theory and Practice, Parenting, Personal Reflections

The Return of Mother’s Little Helper . . .

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This week Allen E. Ivey (the creator of the microcounseling approach) sent me a link to an article claiming that exercise is better for long-term brain functioning than medications. He was “venting” because he thinks this is not “new” information and instead constitutes basic common sense that everyone should embrace. The fact that exercise is good for neurological development and functioning is obvious and it can be frustrating to see the media acting surprised over and over again that life experiences—including counseling and psychotherapy—improves health, life satisfaction, and brain functioning.

Dr. Ivey’s comments and the article he sent reminded me of an unpublished piece I wrote a few years ago. It was a sarcastic commentary on a recent (at the time) publication touting the efficacy of antidepressants in treating depressive symptoms in mothers.

Here’s the piece. Sarcasm included.

The Return of Mother’s Little Helper

            Mother’s little helper is back.

            In a recent landmark study published in the Journal of the American Medical Association, a prestigious group of researchers reported that children with depression improved or recovered when their depressed mothers became less depressed. The researchers were surprised and optimistic that an environmental change—mothers becoming less depressed—could directly help children whom they thought had biological depression. This is an important finding, especially given concerns about prescribing psychotropic medicines directly to children.

            Having closely followed pharmaceutical research in child psychiatry, I’m always skeptical about landmark studies and promising new drugs, but try to stay balanced and hopeful. When I mentioned the research results to my graduate students in counseling and social work, all of whom happened to be women, they felt no need for balance or hope. They responded in unison.

            “No duh. Obviously children will do better if their mothers aren’t depressed. Who needs a study to tell you that?”

            I felt instantly defensive for pharmaceutical researchers everywhere. Okay, maybe the study demonstrated the obvious, but helping children be less depressed is clearly a good thing.

            My students weren’t convinced. They asked, “What treatment did the mothers’ get?”

            “Mostly they got Celexa.” Celexa is very similar to Prozac. They’re both classified as ‘SSRIs,’ meaning they selectively focus on making serotonin more plentiful in crucial brain regions.

            My cynical students pressed on: “Did the makers of Celexa fund the study?”

            “No,” I responded. “Forest Laboratories makes Celexa, but the study was funded by the National Institute of Mental Health.” I felt redeemed; the study was objective.

            “How many of the authors were paid by Forest Laboratories?”

            I happened to have the article with me, so I looked at the back page where financial disclosures are conveniently listed—in very small print. I squinted my way through: “Only 3 authors name Forest Laboratories as giving them money. And Forest Laboratories is thanked in the fine print for supplying all the medication for free.”

            Actually, that wasn’t too bad. There were 15 coauthors on the study; only 20% were linked to Forest Laboratories.

            But my picky students wanted to know about the numbers, so I explained that 151 mothers started the study, but 37 (24.5%) dropped out before three months. Overall, 38 of the 114 remaining mothers recovered from their depressive condition and another 16 improved somewhat. The authors report an overall response rate of 47%.

            A student pecked at her calculator and declared. “No way! Fifty-four of 151 isn’t 47%, it’s 36%; they’re either lying, cheating, or very bad at arithmetic.”

            “How about the kids,” another asked.  “How many of them got better?”

            “Well, it’s complex and hard to say, but overall the researchers report that, of 105 kids, 9 were significantly affected during the study, 4 in a positive direction and 5 in a negative direction.”

            The students mumbled and grumbled. “Are you kidding? That’s not much improvement.” They went on to rant a bit about never knowing a depressed, sleep-deprived mother—including themselves—who looked forward to 18 hours of screeching children and smelly diapers? One student, now a grandmother, noted that Valium (the original mother’s little helper) was the most prescribed drug in the U.S. from 1969-1982 and such a big pharmaceutical success that it inspired a Rolling Stones song. Unfortunately, Valium turned out to be terribly addictive, but now apparently, there’s Celexa, Prozac, and other options for overwhelmed mothers.

            After a few more stories, my students asked, “What were the study’s conclusions?”

            I read aloud: “. . . these findings suggest that it is important to provide vigorous treatment to mothers if they are depressed.”

            Throughout the room, eyes began to roll.

            “That’s a big surprise. They want depressed moms to feel guilty if they don’t take antidepressants. That’s what they mean by ‘vigorous treatment.’ As if a hard life is made better by serotonin? How much did they spend on that study anyway?”

            “I really don’t know,” I answered.  “Maybe half a million?”

            The student with the calculator pecked away again: “They should use that money to do a study on something that might really help depressed mothers.”

            “Like what?” I asked.

            “Like maybe a study on the effectiveness of splitting half a million among 114 moms—that’s over $4,300 each. They could just give them the money, or pay for some counseling and parenting consultations, or health club memberships, or childcare, or massages, or vocational training. Better yet, the researchers could use the money to train fathers to hang around the house and be helpful, rather than lying around watching sports and reading Penthouse.”

            At that point I decided class was over. I’d learned about as much as I could handle for one day.

Counseling and Psychotherapy Theory and Practice, Divorce, Group therapy, Parenting, Uncategorized

The Love Reframe

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Years ago I had the privilege and challenge of teaching a class for divorced parents through Families First in Missoula. About half of the dozen or so participants were mandated to attend. This made for an initially less-than-pleasant opening mood. As I went around the room doing introductions, I came to a man who looked a bit snarly. He announced his name and then said, “But I don’t need no stupid-ass parenting class. The only reason I’m here is because the Judge told me that if I didn’t come, I’d be forced to have supervised visits with my 12 year-old daughter. I’m here, but I don’t need this stupid-ass class.”

 

This was a difficult moment and perhaps because I’m a man, complete with a pesky “Y” chromosome, I was tempted to get into an instant pissing match right there. I felt an urge to say something like, “Well, you may not think you need this class, but apparently the Judge does and so you’d better watch how you talk in here!” Instead, somewhat to my surprise, the following words came into my mind and then out of my mouth, “Well, let me especially thank you for coming because you must really love your daughter to be willing to attend this class.”

 

As the 6 hour marathon class progressed, the snarly man settled in. He was never really pleasant, but he contributed to discussions and politely got in line at the end of class to receive his signed certificate. When I handed him the certificate, I said something like, “Hey, you know you should frame this certificate and put it on your wall at home.”

 

A few weeks after the class I got a call from the guy who didn’t need a stupid-ass parenting class. He sounded different and immediately apologized for “being a jerk in class.” Then he told me in a cracking voice that he’d taken my advice and hung the class certificate on his wall. And then it was clear he was crying when he said, “My daughter came over for an unsupervised visit and when she saw that certificate on the wall, she turned around and gave me this big old hug and said, Daddy, I am so proud of you!”

 

This experience and others like it taught me an important lesson about parents in general and fathers in particular. I’ve learned that underneath the bluster of some irritable and difficult dads there are men who desperately love their children. If we tap this potential, good things can happen.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Multicultural

Talking About White Privilege with Tommy Flanagan

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Tonight I’m in Absarokee, MT and had a chance to talk awhile with my very cool nephew, Tommy Flanagan. Tommy attends Pacific Lutheran University in Tacoma, WA. He shared with me this evening that he’s currently enrolled in several courses focusing on gender, feminist, and cultural issues. We talked about our respective invisible knapsacks and he even asked me how a White guy like me would approach counseling with a Black Lesbian woman. In response, I said, “Well, I just wrote something about that in the Clinical Interviewing text and I had a Black Lesbian woman review it so I would be sure to get some feedback.”

And so here’s the piece:

Working with Gay and Lesbian couples or couples and families from different cultural backgrounds can present clinicians with unique challenges (Bigner & Wetchler, 2004). As discussed in Chapter 11, when a clinician and client have clear and unmistakable differences, the client may initially scrutinize the clinician more closely than if the client and clinician are culturally similar or of the same sexual orientation. These circumstances call for sensitivity, tact, and a discussion of the obvious. Imagine the following scenario:

You’re a white, heterosexual, Christian male. You have a new appointment at 3pm with Sandy Davis and Latisha Johnson for couple counseling. When you get to the waiting room, you see two African American females sitting side by side. You introduce yourself and on the short walk back to your office you mentally process the situation and come to several conclusions: (a) You’re about to meet with an African American Lesbian couple; (b) you’ve never done therapy with this particular cultural minority group; (c) you’re aware of your uncertainty and your concerns about your lack of knowledge makes you feel uncomfortable . . . but also recognize that you want the couple to be comfortable with you . . . and realize they may be feeling similar discomfort about your cultural differences; (d) you are clear that it’s your ethical mandate to provide services to the best of your ability; and (d) although you don’t feel competent to work with this couple, this is a low-income clinic and so the couple may not have many alternatives. How do you proceed?

Below is a brief list of how a clinician might specifically handle this situation. After this list, we provide a description of the underlying principles:

  1. Welcome the couple to your office with the warmth and engagement you offer to all clients (e.g., “I’m glad you could come to the clinic today for your appointment and am happy to meet you. . .”).
  2. Explain confidentiality and the limits of confidentiality. Also, review relevant agency policies that you routinely review with new clients.
  3. If you know the purpose of their visit (e.g., couple counseling) because of the registration form, explain how you usually work with couples.
  4. Let the couple know you’d like them to ask any questions of you they may have . . . but before they ask the questions, explain: “My usual approach with couples is primarily based on work with heterosexual couples. I don’t have experience working with African American Lesbian couples. I’d like to work with you as long as you’re comfortable working with me and it seems like the work is helpful. I know there aren’t lots of couple’s counseling options available. What I propose—if it’s okay with the two of you—is that we start working together today. Today I’ll be asking you directly about your goals for counseling, but also about your interests, values, spirituality and other things that will help me know you better as individuals and as a couple. And toward the end of our session I’ll ask you for feedback about how you think our work together is going and I’ll try to honor that feedback and make adjustments so we can work well together. If, for whatever reason, it looks like we can’t work together effectively, I’ll offer you a good referral to another therapist. What do you think of that plan?”

As described in Chapter 11, the general multicultural competencies include: (a) Awareness (e.g., knowing your biases and limitations); (b) knowledge (e.g., gathering information pertaining to specific cultural groups); and (c) skills (e.g., applying culturally-specific interventions in a culturally sensitive manner). In addition to these competencies, the preceding case illustrates the need for clinicians to explicitly address cultural differences using the following strategies:

  • Cultural universality (treating culturally different clients with same respect you offer to culturally similar clients)
  • Collaboration (working with the clients to understand the particulars of their culture and situation)
  • Feedback (soliciting ongoing feedback regarding client perceptions of how the interview is proceeding and make adjustments based on that feedback).

No clinician can be expected to have awareness, knowledge, and skills for working with every possible diverse client. That being the case, if you also rely on cultural universality, collaboration, and feedback to help strengthen the therapeutic alliance, you’ll have a better chance for therapy to proceed in an ethically and professionally acceptable manner.

 

Counseling and Psychotherapy Theory and Practice

Through the Anger Looking Glass

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This blog was originally posted on the psychotherapy.net website this past week. Psychotherapy.net is a great resource for counselors and psychotherapists . . . http://www.psychotherapy.net/blog/title/through-the-anger-looking-glass

Through the Anger Looking Glass

By John Sommers-Flanagan

A couple weeks ago on NPR’s “Weekend Edition,” the focus was on the 50th anniversary of Betty Freidan’s The Feminine Mystique. In this book Friedan raged against the status of women in the 1960s. Although millions of people have read this feminist manifesto, it seems very few presently understand how anger in general and Friedan’s anger in particular could be a source of insight, motivation, and personal and social transformation.

Anger is an emotional state that has a bad rap. There’s far more written about anger control (“anger management”) than about how anger, when nurtured and examined, can transform. As most mental health professionals already know, anger is an emotion, not a behavior. And emotions are acceptable and desirable. When anger fuels aggressive or destructive behavior is when it becomes problematic.

But since everyone already knows about and talks about the destructive capability of anger—let’s talk about the constructive side of this emotion instead. Hardly anyone articulates anger’s positive qualities as clearly as the feminists. Feminist therapists consider “encouraging anger expression” as a meaningful process goal in psychotherapy for at least five reasons:

  1. Girls and women are typically discouraged from expressing anger directly. Experiencing and expressing anger without repressive cultural consequences can be an exhilarating freedom for females. Similarly, experiencing anger, but not letting it become aggression, is a new and productive process for males.
  2. Anger illuminates. There’s nothing quite like the rush of anger as a signal that something is not quite right. Examined anger can stimulate insight.
  3. Alfred Adler suggested that the purpose of insight in psychotherapy was to enhance motivation. Anger is helpful for both identifying psychotherapy goals AND for mobilizing client motivation.
  4. During psychotherapy anger may occur in-session towards the psychotherapist. Skillful therapists accept this anger without defensiveness and then collaboratively explore the meaning of in-session anger.
  5. Anger is a natural emotional response to oppression and abuse. If clients consistently suppress anger, it inhibits them from experiencing their full range of humanity.

For feminists, one goal of nurturing and exploring client anger is to facilitate feminist consciousness. Feminist consciousness involves females (and males) developing greater awareness of equality and balance in relationships. However, using anger to stimulate insight and motivation is useful in all forms of therapy, not just feminist therapy.

But working with (and not against) anger in psychotherapy is complex. The problem is that anger pulls so strongly for a behavioral response. Reactive anger is destructive. Clients want to let it out. Experiencing and expressing anger feels so intoxicatingly right. Clients want to punch walls. They want to formulate piercing insults. They want to counterattack. Unexamined anger is reactive and vengeful.

Imagine a male client. He’s uncomfortable with how his romantic partner has been treating him. You help him explore these feelings and identify the source; he recognizes that his partner has been treating him disrespectfully. But good psychotherapy doesn’t settle for simple answers. His new insight without further exploration could stimulate retaliatory impulses. Good psychotherapy stays with the process and examines aggressive outcomes. It helps clients explore alternatives. Could he be overreacting? Perhaps the anger is triggering an old wound and it’s not just the partner’s behavior that’s triggering the anger?

Relationships are nearly always a complex mix of past, present, and future impulses and transactions. When anger is respected as a signal and clients take ownership of their anger, good things can happen. It can be used to help clients become more skilled at identifying and articulating underlying sadness, hurt, and disappointment. Clients can emerge from psychotherapy with not only new insights, but increased responsibility for their behavior and more refined skills for communicating feelings and thoughts without blaming anger, but in a way that serves as an invitation for greater intimacy and deeper partnership.

None of this would be possible without the clarifying stimulation of anger and a collaborative psychotherapist who’s able to help clients face, embrace, and understand the many layers of meaning underneath your anger. And it’s about time we learned a lesson from the feminists and started giving anger the respect it deserves.

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

Musings About Online Counseling

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As Rita and I updated the Clinical Interviewing text, we did a little web-searching for online counseling resources and the excerpt below includes our musings on this very interesting topic.

From Clinical Interviewing, 4th ed, updated, SF & SF, 2012

Online Counseling: Ethics and Reality

As a part of reviewing information for this chapter, we perused Internet therapy options available to potential consumers. Previous publications suggested a possible plethora of Internet counseling and psychotherapy providers with questionable professional credentials (Heinlen, Welfel, Richmond, & O’Donnell, 2003; Shaw & Shaw, 2006). Although we hoped that Internet service provision standards had improved, we weren’t overly impressed with our results. Generally, we found that most providers may have more expertise in business and marketing than they do in professional clinical work. Affixed on this foundation of business and marketing, we found two distinct approaches: the more ethical and the less ethical.

The Less Ethical Approach

Many providers offer online services but don’t acknowledge having specific credentials (e.g., a license) typically associated with clinical expertise. For example, practitioners with bachelor’s degrees (or less) made statements like the following:

“I am a counselor, life coach, and spiritual teacher with over 20 years of experience. I have studied the fields of counseling, psychology, personal growth, relationships, communications, business, computer programming and technology, languages, spirituality, metaphysics and energetic bodywork! In addition to my training, a [sic] 18-year relationship with my second husband has deepened my capacity to help others with relationship issues.”

This sort of enthusiastic introduction was typically followed by an equally enthusiastic statement about the breadth of services offered:

“My online counseling services specialties include, but are not limited to: anxiety/panic, self-esteem, highly sensitive people, couples counseling, relationship advice, life and career coaching, emotional intelligence, personal growth, affairs, guilt issues, work and career, trust issues, abuse/boundary issues, communication skills, conflict resolution, grief and loss, emotional numbness, spiritual development, stress management, blame, court-ordered counseling, codependency, problem resolution, jealousy, codependency and attachment, anger and depression, food and body, and developing peace of mind.”

Curiously, we found that the broad range of claims on websites such as these did not move us toward developing or experiencing peace of mind.

The More Ethical Approach

There were also websites that included professional, licensed providers. For example, one website listed and described eight licensed practitioners with backgrounds in professional counseling, social work, and psychology. These professionals offered webcam therapy, text therapy, e-mail therapy, and telephone therapy.

Prices included:

  • E-mail therapy: $25 per online counselor reply
  • Unlimited e-mail therapy: $200 per month
  • Chat therapy: $45 per 50-minute session
  • Telephone therapy: $80 per 50-minute session
  • Webcam therapy: $80 per 50-minute session

The more ethical professional Internet services also tended to include information related to theoretical orientation. For example, a “postmodern” approach was described as involving: “Staying positive . . . focused on the here and now . . . offering solutions that meet your needs . . . a collaborative and respectful environment . . . quick results . . .”

How to Choose an Internet Services Provider

The National Directory of Online Counselors now exists to help consumers choose an online provider. They state:

“We have personally verified the credentials and the websites of each therapist listed in the National Directory of Online Counselors. Feel assured that the therapists listed are state board licensed, have a Master’s Degree or Doctoral Degree in a mental health discipline, and have online counseling experience.”

The listed therapists and websites are set up and ready to handle secure communication, and offer various services such as eMail Sessions, Chat Sessions, and Telephone Sessions. All work conducted by the professional licensed therapists meet[s] strict confidentiality standards overseen by their professional state board.

Both of these distinct approaches to online therapy emphasize that help is only a mouse click away.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Exploring Empathy III

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This is a practice-based situation that makes for good discussion about how empathic and how leading it’s appropriate to be in a counseling or psychotherapy session.

Putting It in Practice 5.1

What and How to Validate? Empathic Responding to Trauma and Abuse

Empathy often includes validation of client emotional experiences. But sometimes clients have ambivalent feelings about their own experiences which makes empathic validation complicated. This is especially possible in cases of trauma and abuse where victims can and do experience victim guilt—feeling as though they caused their own abusive experiences. For example, take the following Therapist-client interaction:

Therapist: “Can you think of a time when you felt unfairly treated? Perhaps punished when you didn’t deserve it?”

Client: “No, not really. (15-second pause) Well, I guess there was this one time. I was supposed to clean the house for my mother while she was gone. It wasn’t done when she got back, and she broke a broom over my back.”

Therapist: “She broke a broom over your back?” (stated with a slight inflection, indicating possible disapproval or surprise with the mother’s behavior)

Client: “Yeah. I probably deserved it, though. The house wasn’t cleaned like she had asked.”

In this situation, the client seems to have mixed feelings about her mother. On the one hand, the mother treated her unfairly; on the other hand, the client felt guilty because she saw herself as a bad girl who didn’t follow her mother’s directions. The therapist was trying to convey empathy through voice tone and inflection. This technique was chosen due to concerns that focusing too strongly on the client’s guilt or indignation and anger might prematurely shut down exploration of the client’s ambivalent feelings. Despite the therapist’s minimal expression of empathy, the client defended her mother’s punitive actions. This suggests that the client had already accepted (by age 11, and still accepted at age 42) her mother’s negative evaluation of her. From a person-centered or psychoanalytic perspective, a stronger supportive statement such as “That’s just abuse, mothers should never break brooms over their daughters’ backs” may have closed off any exploration of the client’s victim guilt about the incident.

Alternatively, this is a situation where gentle, open and empathic questioning might help deepen the therapist’s understanding of the client’s unique personal experience and help her explore other feelings, like anger, that she might have in response to her mother’s abuse. For example, the therapist could have asked:

I hear you saying that maybe you feel you deserved to be hit by your mother in that situation, but I also can’t help but wonder . . . what other feelings you might have?

Or, the therapist might use a third-person or relationship question to help the client engage in empathic perspective-taking herself:

What if you had a friend who experienced something like what you experienced? What would you say to your friend?

From a nondirective perspective, sensitive nondirective responses that communicate empathy through voice tone, facial expression, and feeling reflection are usually more advantageous than open support and sympathy. There’s always time for open support later, after the client has explored both sides of the issue.

In first version of this interaction, the therapist used a nondirective model, expressing only nonverbal empathy for the client’s abuse experience. He didn’t openly criticize or judge the mother’s violence. Do you think the therapist might have been too nondirective—in some ways aligning with the part of the client that felt her mother was justified in abusing her? Is it possible that the client actually might have been more able to explore her anger toward her mother if the therapist had led her in that direction using immediacy (i.e., empathic self-disclosure):

“When I imagine myself in your situation, I can feel the guilt you feel, but also, a part of me feels angry that my mother would care so much about housecleaning and so little about me.”

This self-disclosure is both empathic and leading. Do you think it’s too leading? Or do you think it’s a better response than the neutrality often emphasized in psychoanalytic therapies? These are important issues to discuss as you intentionally develop your own therapy style. . . and so be sure to discuss the variety of ways you might respond empathically and therapeutically to this client scenario.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Exploring Empathy — Part I

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Happy Saturday. This post is the first of a three-part preview of our discussion on Empathy from Clinical Interviewing, 5th Edition.

See: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=ntt_at_ep_dpt_1

Empathic Understanding

Empathic understanding is a central concept in counseling and psychotherapy. Rogers (1980) defined empathy as:

. . . the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. [It is] this ability to see completely through the client’s eyes, to adopt his frame of reference, (p. 85) . . .  It means entering the private perceptual world of the other . . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . . . It means sensing meanings of which he or she is scarcely aware. (p. 142)

Rogers’s definition of empathy is complex. It includes several components.

  • Therapist ability or skill
  • Therapist attitude or willingness
  • A focus on client thoughts, feelings, and struggles
  • Adopting the client’s frame of reference or perspective-taking
  • Entering the client’s private perceptual world
  • Moment-to-moment sensitivity to felt meanings
  • Sensing meanings of which the client is barely aware

A Deeper Look at Empathy

As with congruence and unconditional positive regard, the complexity of Rogers’s definition has made research on empathy challenging. Many different definitions of empathy have been articulated (Batson, 2009; Clark, 2010; Duan & Hill, 1996). According to Elliott, Bohart, Watson, & Greenberg (2011), recent advances in neuroscience have helped consolidate empathy definitions into three core subprocesses:

  1. Emotional simulation: This is a process that allows one person to experientially mirror another’s emotions. Emotional simulation likely involves mirror neurons and various brain structures within the limbic system (e.g., insula).
  2. Perspective-taking: This is a more intellectual or conceptual process that appears to involve the pre-frontal and temporal cortices.
  3. Emotion regulation: This involves a process of re-appraising or soothing of one’s own emotional reactions. It appears to be a springboard for a helping response. Emotional regulation may involve the orbitofrontal cortex and prefrontal and right inferior parietal cortices.

Empathy is an interpersonal process that requires experiencing, inference, and action. In chapter 1 we noted that playing a note on one violin will cause a string on another violin to vibrate as well, albeit at a lower level. In therapy, this has been referred to as resonance. Most people have had the experience of feeling tears well up at a movie or while someone talks about pain or trauma. This is the experiential component of empathy that Elliot et al., (2011) referred to as emotional simulation).

Beyond this physical/experiential resonance, one person cannot objectively know another person’s emotions and thoughts. Consequently, at some level, empathy always involves subjective inference. This process has been referred to as perspective-taking in the scientific literature and is considered a cognitive or intellectual requirement of empathy (Stocks, Lishner, Waits, & Downum, 2011).

Empathy—at least within the context of a clinical interview—also requires action. Therapists must cope with and process the emotions that are triggered and then provide an empathic response. Most commonly this involves reflection of feeling or feeling validation, but nearly every potential interviewing response or behavior can include verbal and nonverbal components that include empathy. The action component of empathy is likely what Elliot et al., are referring to with the term emotional regulation.

Simple guides to experiencing and expressing empathy can help you develop your empathic abilities. At the same time, we don’t believe any single strategy will help you develop the complete empathy package. For example, Carkhuff (1987) referred to the intellectual or perspective-taking part of empathy as “asking the empathy question” (p. 100). He wrote:

By answering the empathy question we try to understand the feelings expressed by our helpee. We summarize the clues to the helpee’s feelings and then answer the question, How would I feel if I were Tom and saying these things? (p. 101).

Carkhuff’s empathy question is a useful tool for tuning into client feelings, but it also oversimplifies the empathic process in at least two ways. First, it assumes therapists have a perfectly calibrated internal affective barometer. Unfortunately this is not the case as clients and therapists can have such different personal experiences that the empathy question produces completely inaccurate results; just because you would feel a particular way if you were in the client’s shoes doesn’t mean the client feels the same way. Sometimes empathic responses are a projection of the therapist’s feelings onto the client. If you rely solely on Carkhuff’s empathy question, you risk projecting your own feelings onto clients.

Consider what might happen if a therapist tends towards pessimism, while her client usually puts on a happy face. The following exchange might occur:

Client: “I don’t know why my dad wants us to come to therapy now and talk to each other. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would accept it too.”

Therapist: “It must make you angry to have a father who can’t communicate effectively with you.”

Client: “Not at all. I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”

In this case, asking the empathy question: “How would I feel if I could never communicate well with my father?” may produce angry feelings in the therapist. This process consequently results in the therapist projecting her own feelings onto the client—which turns out to be a poor fit for the client. Accurate empathic responding stays close to client word content and nonverbal messages. If this client had previously expressed anger or was looking upset or angry (e.g., angry facial expression, raised voice), the therapist might resonate with and choose to reflect anger. However, instead the therapist’s comment is inaccurate and is rejected by the client. The therapist could have stayed more closely with what her client expressed by focusing on key words. For example:

Coming into therapy now doesn’t make much sense to you. Maybe you used to have feelings about your lack of communication with your dad, but it sounds like at this point you feel pretty numb about the whole situation and just want to move on.

This second response is more accurate. It touches on how the client felt before, what she presently thinks, as well as the numbed affective response. The client may well have unresolved sadness, anger, or disappointment, but for the therapist to connect with these buried feelings requires a more interpretive intervention. Recall from Chapter 3 that interpretations and interpretive feeling reflections must be supported by adequate evidence.

To help with the intellectual process of perspective-taking, instead of focusing exclusively on what you’d feel if you were in your client’s shoes, you can expand your repertoire in at least three ways:

  1. Reflect on how other clients have felt or might feel
  2. Reflect on how your friends or family might feel and think in response to this particular experience
  3. Read and study about experiences similar to your clients’.

Based on Rogers’s writings, Clark (2010) referred to intellectual approaches to expanding your empathic understanding as objective empathy. Objective empathy involves using “theoretically informed observational data and reputable sources in the service of understanding a client” (Clark, 2010, p. 349). Objective empathy is based on the application of external knowledge to the empathic process—this can expand your empathic responding beyond your own personal experiences.

Rogers (1961) also emphasized that feeling reflections should be stated tentatively so clients can freely accept or dismiss them. Elliot et al., (2011) articulated the tentative quality of empathy very well: “Empathy should always be offered with humility and held lightly, ready to be corrected” (p. 147)

From a psychoanalytic perspective, it’s possible to show empathy not only for what clients are saying, but also for their defensive style (e.g., if they’re using defense mechanisms such as rationalization or denial, show empathy for those):

Client: “I don’t know why my dad wants us to come to therapy now. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would.”

Therapist: “Coming into therapy now doesn’t make much sense to you. Maybe you had feelings about your lack of communication with your dad before, but it sounds like you feel pretty numb about the whole situation now.”

Client: “Yeah, I guess so. I think I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”

Therapist: “Maybe one of the ways you protect yourself from feeling anything is to distance yourself from your parents. Otherwise, it could still bother you, I suppose.”

Client: “Yeah. I guess if I let myself get close to my parents again, my dad’s pathetic inability to communicate would bug me again.”

This client still has feelings about her father’s poor communication. One of the functions of accurate empathy is to facilitate the exploration of feelings or emotions (Greenberg, Watson, Elliot, & Bohart, 2001). By staying with the client’s feelings instead of projecting her own feelings onto the client, the therapist is more likely to facilitate emotional exploration.

A second way in which Carkhuff’s (1987) empathy question is simplistic is that it treats empathy as if it had to do only with accurately reflecting client feelings. Although accurate feeling reflection is an important part of empathy, as Rogers (1961) and others have discussed, empathy also involves thinking and experiencing with clients (Akhtar, 2007). Additionally, Rogers’s use of empathy with clients frequently focused less on emotions and more on meaning. Recall that in his original definition, Rogers wrote that empathy involved: “. . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . .” (p. 142). And so empathic understanding is not simple, it involves feeling with, thinking with, sensing felt meanings, and reflecting all this and more back to the client with a humility that acknowledges deep respect for the validity of the client’s own experiences.

More to come on this tomorrow in “Exploring Empathy” Part II.

References

Akhtar, S. (Ed.). (2007). Listening to others: Developmental and clinical aspects of empathy and attunement Lanham, MD, US: Jason Aronson.

Carkhuff, R. R. (1987). The art of helping (6th ed.). Amherst, MA: Human Resource Development Press.

Clark, A. J. (2010). Empathy: An integral model in the counseling process. Journal of Counseling & Development, 88, 348-356.

Greenberg, L. S., Watson, J. C., Elliot, R., & Bohart, A. C. (2001). Empathy. Psychotherapy: Theory, Research, Practice, Training, 38(4), 380-384.

Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.

Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.

Stocks, E. L., Lishner, D. A., Waits, B. L., & Downum, E. M. (2011). I’m embarrassed for you: The effect of valuing and perspective taking on empathic embarrassment and empathic concern. Journal of Applied Social Psychology, 41(1), 1-26. doi: http://dx.doi.org/10.1111/j.1559-1816.2010.00699.x