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Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Uncategorized

Respecting the Client’s Perspective – Even When We Think We Know Better

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There are so many ways we can . . . as therapists . . . subtly (or less so) disrespect our client’s perspective. Here’s a small example from the revision of Clinical Interviewing (5th ed).

Interviewers can negatively judge or disrespect the client’s perspective in many ways. Very recently, I (John) became somewhat preoccupied about convincing a client that she wasn’t really “bipolar.” Despite my good intentions (it seemed to me that the young woman would be better off without the bipolar label), there was something useful or important for the client about holding onto her bipolar identity. Of course, as a “psychological expert” I thought it was ludicrous. I thought it obscured her many personal strengths with a label that diminished her personhood. Therefore, I tried my best to shove my opinion into her belief system. For better or worse, I was unsuccessful.

What’s clear about this example is that, despite our general expertise in mental health matters, as mental health professionals we need to work hard to respect our clients’ worldviews. In recent years practitioners from many theoretical perspectives have become more firm about the need for the expert therapist to take a back seat to the client’s personal lived experience. It’s now more important than ever for interviewers to acknowledge and embrace client expertness. This may be partly due to our increasing awareness (as mental health professionals and advocates) that clients may have very divergent views of themselves and the world.

In the end, who am I to tell my client that she is better off without a bipolar label? What if that label somehow, perhaps even in a twisted way, offers her solace. Perhaps she feels comfort in a label that helps explain her behavior to herself. Perhaps she is not ready—yet—to let go of the bipolar label. Perhaps she never will—and that may be the best outcome.

Whatever their theoretical orientation, effective interviewers respect their client’s personal expertise or perspective. We need that expertise. If the client is unwilling to collaborate with us by sharing her or his expertise and experience, we lose at least some of our potency as helpers.

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John offers his brother-in-law some advice.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Thoughts on the Relationship Between Cleavage and Professional Counseling and Psychotherapy

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The following is a short discussion about cleavage in counseling and psychotherapy.  We’re not especially trying to be provocative (which is one reason why no photo accompanies this blog post) and so we’re interested in your thoughts on this short excerpt BEFORE we include it in the 5th edition of our Clinical Interviewing text.

[Excerpt starts here] For the first time ever in a textbook (and we’ve been writing them since 1993), we’ve decided to include a discussion on cleavage. Of course, this makes us feel exceptionally old, but we hope it also might reflect wisdom and perspective that comes with aging. 

In recent years we’ve noticed a greater tendency for female counseling and psychology students (especially younger females) to dress in ways that can be viewed as somewhat sexual. This includes, but is not limited to low necklines that show a considerable amount of cleavage. This issue was discussed on a series of postings on the Counselor Education and Supervision listserv which includes primarily participants who teach in master’s and doctoral programs in counseling. Most of the postings included some portion of the following themes.

  • Female (and male) students have the right to express themselves via how they dress
  • Commenting on how women dress and making specific recommendations may be viewed as sexist or inappropriately limiting
  • It is true that women should be able to dress any way they want
  • It is also true that specific agencies and institutions have the right to establish dress codes or otherwise dictate how their paid employees and volunteers dress
  • Despite egalitarian and feminist efforts to free women from the shackles of a patriarchal society, how women dress is still interpreted as having certain socially constructed messages that often, but not always, pertain to sex and sexuality
  • Although efforts to change socially constructed ideas about women dressing “sexy” can include activities like campus “slut-walks,” the clinical interview is probably not the appropriate venue for initiating a discourse on social and feminist change
  • For better or worse, it’s a fact that both middle-school males and middle-aged men (and many “populations” in between) are likely to be distracted—and their ability to profit from a counseling experience may be compromised—if they’re offered an opportunity for a close up view of their therapist’s breasts
  • At the very least, excessive cleavage (please don’t ask us to define this phrase) is less likely to contribute to positive therapy outcomes and more likely to stimulate sexual fantasies—which we believe is probably contrary to the goals of most therapists
  • It may be useful to have young women watch themselves on video from the viewpoint of a client (of either sex) that might feel attracted to them and then discuss how to manage sexual attraction that might occur during therapy

It’s obvious that when it comes to clinical interviewers showing cleavage, we don’t have all the perfect answers. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend that you take time to think about this issue and hope you might also consider discussing cleavage issuesJ with your class or your supervisor.

Info on Clinical Interviewing – the text and videos – is at: http://lp.wileypub.com/SommersFlanagan/

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

A Wiley Website with Info about our Brand New Counseling and Psychotherapy Videos

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This spring and summer Rita and I have been working with John Wiley & Sons to produce DVDs to go with our textbooks Clinical Interviewing and Counseling and Psychotherapy Theories in Context and Practice. The Clinical Interviewing DVD is out and the Theories DVD will be available soon. There’s a new website with information about this at: http://lp.wileypub.com/SommersFlanagan/

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John reading the new textbooks to his twin grandchildren (who look quite excited about learning how to do psychotherapy).

 

Counseling and Psychotherapy Theory and Practice

Is Solution-Focused Therapy as Powerfully Effective as Solution-Focused Therapists Would Have Us Believe?

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[This Blog is adapted from a previous blog posted on psychotherapy.net]

Solution-focused therapy is very popular. But is it effective?

Beginning in the 1980s, solution-focused therapy hit the mainstream and many mental health providers (and third-party payers) continue to sing the praises of its brevity and effectiveness. For example, in a 2009 book chapter Sara Smock claimed, “. . . there are numerous studies, several reviews of the research, and a few meta-analyses completed that showcase [solution-focused therapy’s] effectiveness.”

Really?

Solution-focused counseling and psychotherapy has deep roots in post-modern constructive theory. As Michael Hoyt once famously articulated, this perspective is based on “the construction that we are constructive.” In other words, solution-focused therapists believe clients and therapists build their own realities.

Ever since 2003, my personal construction of reality has been laced with skepticism. That was the year President George W. Bush included 63 references to “weapons of mass destruction” in his State of the Union address (I’m estimating here, using my own particular spin, but that’s the nature of a constructive perspective). As it turned out, there were no weapons of mass destruction, but President Bush’s “If I say it enough, it will become reality” message had a powerful effect on public perception.

From the constructive or solution-focused perspective, perception IS reality. Remember that. It applies to the solution-focused therapist’s view of solution-focused therapy effectiveness.

I recall hearing many presenters tell me that solution-focused therapy is powerful and effective. Or maybe it was powerfully effective. And I recall reading books and articles that similarly referred to the power and effectiveness of solution-focused therapy. Now we could just take their word for it, but I still can’t help but wonder: “What does the scientific research say about the efficacy of solution-focused therapy anyway?”

Here’s a quick historical tour of scientific reality.

  • In 1996, Scott Miller and colleagues noted: “In spite of having been around for ten years, no well-controlled, scientifically sound outcome studies on solution-focused therapy have ever been conducted or published in any peer-reviewed professional journal.”
  • In 2000, Gingerich & Eisengart identified 15 studies and after analyzing the research, they stated: “. . . we cannot conclude that [solution-focused brief therapy] has been shown to be efficacious.”
  • In 2008, Johnny Kim reported on 22 solution-focused outcomes studies. He noted that the only studies to show statistical significance were 12 studies focusing on internalizing disorders. Kim reported an effect size of d = .26 for these 12 studies [this is a rather small effect size].
  • In 2009, Jacqueline Corcoran and Vijayan Pillai concluded: “. . . practitioners should understand there is not a strong evidence basis for solution-focused therapy at this point in time.”

Now don’t get me wrong. As a mental health professional and professor, I believe solution-focused techniques and approaches can be very helpful . . . sometimes. However, my scientific training stops me from claiming that solution-focused approaches are highly effective. Although solution-focused techniques can be useful, psychotherapy often requires long term work that focuses not only on strengths, but problems as well.

So what’s the bottom line?

While in a heated argument with an umpire, Yogi Berra once said: “I wouldn’t have seen it if I hadn’t believed it!” This is, of course, an apt description of the powerful confirmation bias that affects everyone. We can’t help but look for evidence to support our pre-existing beliefs . . . which is one of the reasons why even modernist scientific research can’t always be trusted.  But this is why we bother doing the research. We need to step back from our constructed and enthusiastic realities and try to see things as objectively as possible, recognizing that absolute objectivity is impossible.

Despite strong beliefs to the contrary, there were no weapons of mass destruction. And currently, the evidence indicates that solution-focused therapy is NOT powerfully effective.

 

Counseling and Psychotherapy Theory and Practice

John Dreams About Counseling and Psychotherapy Theories

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One morning, long ago, John woke up in the midst of a dream about having written a theories book. Over breakfast, John shared his dream with Rita. Rita said, “John go sit down, relax, and I’ll sit behind you as you free associate to the dream” (see Chapter 2, Psychoanalytic Approaches).

As John was free-associating, Rita tried to gently share her perspective using a two-person, relational psychotherapy model. She noted it had been her lived experience that, in fact, they had already written a theories text together and that he must have been dreaming of a 2nd edition. John jumped out of his seat and shouted, “You’re right! I AM dreaming about a 2nd edition.”

This profound insight led to further therapeutic exploration. Rita had John look at the purpose of his dream (see Chapter 3, Individual Psychology); then he acted out the dream, playing the role of each object and character (see Chapter 6; Gestalt therapy). When he acted out the role of Rita, he became exceedingly enthusiastic about the 2nd edition. She, of course, accused him of projection while he suggested that perhaps he had absorbed her thoughts in a psychic process related to Jung’s idea of the collective unconscious. Rita noted that was a possibility, but then suggested we leave Jung and the collective unconscious online where it belongs (see the Jungian chapter in the big contemporary collective unconscious of the internet online at ** ).

For the next week, Rita listened to and resonated with John as he talked about the 2nd edition. She provided an environment characterized by congruence, unconditional positive regard, and empathic understanding (see Chapter 5, Person-Centered approaches). John flourished in that environment, but sneakily decided to play a little behavioral trick on Rita. Every time she mentioned the word theories he would say “Yesss!,” pat her affectionately on the shoulder and offer her a piece of dark chocolate (see Chapter 7, Behavior therapy). Later he took a big risk and allowed a little cognition into the scenario, asking her: “Hey, what are you thinking?” (see Chapter 8, Cognitive-behavioral therapy).

Rita WAS still thinking it was too much work and not enough play. John responded by offering to update his feminist views and involvement if she would only reconsider (see Chapter 10, Feminist therapy); he also emphasized to Rita that writing a second edition would help them discover more meaning in life and perhaps they would experience the splendor of awe (see Chapter 4, Existential therapy). Rita still seemed ambivalent and so John asked himself the four questions of choice theory (see Chapter 9, Choice theory and reality therapy):

  1. What do you want?
  2. What are you doing?
  3. Is it working?
  4. Should you make a new plan?

It was time for a new plan, which led John to develop a new narrative (see Chapter 11, Narrative therapy).  He had a sparkling moment where he brought in and articulated many different minority voices whose discourse had been neglected (see Chapter 13; Multicultural therapy). He also got his daughters to support him and conducted a short family intervention (see Chapter 12, Family systems therapy).

Something in the mix seemed to work: Rita came to him and said . . . “I’ve got the solution, we need to do something different while we’re doing something the same and approach this whole thing with a new attitude of mindful acceptance” (see Chapter 11, Solution-focused therapy and Chapter 14, Integrational approaches). To this John responded with his own version of radical acceptance saying: “That’s a perfect idea and you know, I think it will get even better over a nice dinner.” It was at that nice dinner that they began to articulate their main goals for the second edition of Counseling and Psychotherapy Theories in Context and Practice.

Counseling and Psychotherapy Theory and Practice

The Efficacy of Solution-Focused Therapy

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The Efficacy of Solution-Focused Therapy

For years I’ve wondered about what the research says about the efficacy of solution-focused therapy. While revising our theories text, I reviewed some of the literature. If you’re interested, I published a short blog about it on psychotherapy.net. Check it out. http://www.psychotherapy.net/blog/title/the-miraculous-or-not-efficacy-of-solution-focused-therapy

Counseling and Psychotherapy Theory and Practice

Imaginal or In Vivo Exposure and Desensitization

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Systematic desensitization is a form of exposure treatment. Exposure treatments are based on the principle that clients are best treated by exposure to the very thing they want to avoid: the stimulus that evokes intense fear, anxiety, or other painful emotions. Mowrer (1947) used a two-factor theory of learning, based on animal studies, to explain how avoidance conditioning works. First, he explained that animals originally learn to fear a particular stimulus through classical conditioning. For example, a dog may learn to fear its owner’s voice when the owner yells due to the discovery of an unwelcome pile on the living room carpet. Then, if the dog remains in the room with its owner, fear continues to escalate.

Second, Mowrer explained that avoidance behavior is reinforced via operant conditioning. Specifically, if the dog manages to hide under the bed or dash out the front door of the house, it’s likely to experience decreased fear and anxiety. Consequently, the avoidance behavior—running away and hiding—is negatively reinforced because it relieves fear, anxiety, and discomfort. Negative reinforcement is defined as the strengthening of a behavioral response by reducing or eliminating an aversive stimulus (like fear and anxiety).

Note that exposure via systematic desensitization and the other procedures detailed hereafter are distinctively behavioral. However, the concept that psychological health is enhanced when clients face and embrace their fears is consistent with existential and Jungian theory (van Deurzen, 2010; see online Jungian chapter: Link to be set up**).

There are three ways to expose clients to their fears during systematic desensitization. First, exposure to fears can be accomplished through mental imagery. This approach can be more convenient and allows clients to complete treatment without ever leaving their therapist’s office. Second, in vivo (direct exposure to the feared stimulus) is also possible. This option can be more complex (e.g., going to a dental office to provide exposure for a client with a dental phobia), but appears to produce outcomes superior to imaginal exposure (Emmelkamp, 1994). Third, computer simulation (virtual reality) has been successfully used as a means of exposing clients to feared stimuli (Emmelkamp et al., 2001; Emmelkamp, Bruynzeel, Drost, & van der Mast, 2001).

Psychoeducation is critical to effective exposure treatment. D. Dobson and K. S. Dobson (2009) state:

A crucial element of effective exposure is the provision of a solid rationale to encourage your client to take the risks involved in this strategy. A good therapeutic alliance is absolutely essential for exposure to occur. (p. 104)

Further, D. Dobson and K. S. Dobson (2009) provide a sample client handout that helps inform clients of the exposure rationale and procedure.

Exposure treatment means gradually and systematically exposing yourself to situations that create some anxiety. You can then prove to yourself that you can handle these feared situations, as your body learns to become more comfortable. Exposure treatment is extremely important in your recovery and involves taking controlled risks. For exposure treatment to work, you should experience some anxiety—too little won’t be enough to put you in your discomfort zone so you can prove your fears wrong. Too much anxiety means that you may not pay attention to what is going on in the situation. If you are too uncomfortable, it may be hard to try the same thing again. Generally, effective exposure involves experiencing anxiety that is around 70 out of 100 on your Subjective Units of Distress Scale. Expect to feel some anxiety. As you become more comfortable with the situation, you can then move on to the next step. Exposure should be structured, planned, and predictable. It must be within your control, not anyone else’s. (p. 104)

Massed (Intensive) or Spaced (Graduated) Exposure Sessions

Behavior therapists continue to optimize methods for extinguishing fear responses. One question being examined empirically is this: Is desensitization more effective when clients are directly exposed to feared stimuli during a single prolonged session (e.g., one 3-hour session; aka massed exposure) or when they’re slowly and incrementally exposed to feared stimuli during a series of shorter sessions (such as five 1-hour sessions; aka spaced exposure)? Initially, it was thought that massed exposure might result in higher dropout rates, greater likelihood of fear relapse, and a higher client stress. However, research suggests that massed and spaced exposure desensitization strategies yield minimal differences in efficacy differences (Ost, Alm, Brandberg, & Breitholz, 2001).

Virtual Reality Exposure

Technological advancements have led to potential modifications in systematic desensitization procedures. Specifically, virtual reality exposure, a procedure wherein clients are immersed in a real-time computer-generated virtual environment, has been empirically evaluated as an alternative to imaginal or in-vivo exposure in cases of acrophobia (fear of heights), flight phobia, spider phobia, and other anxiety disorders (Krijn et al., 2007; Ruwaard, Broeksteeg, Schrieken, Emmelkamp, & Lange, 2010).

In a meta-analysis of 18 outcome studies, Powers and Emmelkamp (2008) reported a large effect size (d = 1.11) as compared to no treatment and a small effect size (d = .35) when compared to in vivo control conditions. These results suggest that virtual reality exposure may be as efficacious or even more so than in vivo exposure.

Interoceptive Exposure

Typical panic-prone individuals are highly sensitive to internal physical cues (e.g., increased heart rate, increased respiration, and dizziness). They become especially reactive when those cues are associated with environmental situations viewed as potentially causing anxiety (Story & Craske, 2008). Physical cues or sensations are then interpreted as signs of physical illness, impending death, or imminent loss of consciousness (and associated humiliation). Although specific cognitive techniques have been developed to treat clients’ tendencies to catastrophically overinterpret bodily sensations, a more behavioral technique, interoceptive exposure, has been developed to help clients learn, through exposure and practice, to deal more effectively with physical aspects of intense anxiety or panic (Lee et al., 2006; Stewart & Watt, 2008).

Interoceptive exposure is identical to other exposure techniques except that the target exposure stimuli are internal physical cues. There are at least six interoceptive exposure tasks that reliably trigger anxiety (Lee et al., 2006). They include:

  • Hyperventilation
  • Holding breath
  • Breathing through a straw
  • Spinning in circles
  • Shaking head
  • Chest breathing

Of course, before interoceptive exposure is initiated, clients receive education about body sensations, learn relaxation skills (e.g., breathing training), and learn cognitive restructuring skills. Through repeated successful exposure, clients become desensitized to previously feared physical cues (Forsyth, Fusé, & Acheson, 2009).

Response and Ritual Prevention

Mowrer’s two-factor theory suggests that, when a client avoids or escapes a feared or distressing situation or stimulus, the maladaptive avoidance behavior is negatively reinforced (i.e., when the client feels relief from the negative anxiety, fear, or distress, the avoidance or escape behavior is reinforced or strengthened; Spiegler & Guevremont, 2010). Many examples of this negative reinforcement cycle are present across the spectrum of mental disorders. For example, clients with Bulimia Nervosa who purge after eating specific “forbidden” foods are relieving themselves from the anxiety and discomfort they experience upon ingesting the foods (Agras, Schneider, Arnow, Raeburn, & Telch, 1989). Therefore, purging behavior is negatively reinforced. Similarly, when a phobic client escapes from a phobic object or situation, or when a client with obsessive-compulsive symptoms engages in a repeated washing or checking behavior, negative reinforcement of maladaptive behavior occurs (Franklin & Foa, 1998; Franklin, Ledley, & Foa, 2009; March, Franklin, Nelson, & Foa, 2001).

It follows that, to be effective, exposure-based desensitization treatment must include response prevention. With the therapist’s assistance, the client with bulimia is prevented from vomiting after ingesting a forbidden cookie, the agoraphobic client is prevented from fleeing a public place when anxiety begins to mount, and the client with Obsessive-Compulsive Disorder is prevented from washing his or her hands following exposure to a “contaminated” object. Without response or ritual prevention, the treatment may exacerbate the condition it was designed to treat. Research indicates that exposure plus response prevention can produce significant brain changes in as few as three psychotherapy sessions (Schwartz, Gulliford, Stier, & Thienemann, 2005; Schwartz, Stoessel, Baxter, Martin, & Phelps, 1996).

 

Counseling and Psychotherapy Theory and Practice

Reflections on Another Counselng and Psychotherapy Video Shoot

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Yesterday I got to demonstrate skills associated with four different therapy approaches: Reality therapy, psychoanalytic therapy, cognitive-behavioral therapy, and Adlerian therapy.

Overall the video shoot went well, but I was surprised that of these four approaches, in many ways I felt most comfortable with reality therapy. I hadn’t expected that. Many people don’t “get” reality therapy and think it’s either a form of cognitive-behavioral therapy or a highly confrontational approach wherein therapists sternly confront their clients with cold, cruel, reality.

But reality therapy isn’t a form of CBT and it’s not confrontational. What I found myself doing in the reality therapy demo was following the sage guidance of Robert Wubbolding who formulated four BIG questions that stand at the heart of reality therapy. The questions would be good for everyone to memorize and can, when applied gently and persistently, help get people back onto a positive track. The questions are:

1. What do you want?

2. What are you doing?

3. Is it working?

4. Should you make a new plan?

Wubbolding has written several books on reality therapy and is taking up the torch for William Glasser, who was the original developer of this approach. In particular, I recommend Wubbolding’s books because they will help guide you in how to ask questions to help clients explore these four very important questions. I can even use them right now:

What do I want? — A good night’s sleep.

What am I doing? — Typing up this blog

Is it working? — Nope!

Should I make a new plan? — Good night!