Category Archives: Tough Kids

Boys Will Be Boys . . . Unless We Teach Them Something Better

What follows is a reprint from the ACA blog I wrote a couple weeks ago just in case you didn’t catch that. Have an excellent weekend.

Some of you may already be aware of Rosalind Wiseman’s work. She initially became recognized as a national parenting authority with the publication of her popular book, “Queen Bees and Wannabees” (2003).  This book inspired the movie “Mean Girls.” Despite her lack of academic credentials (a B.A. in Political Science from Occidental College), she has done some good work around the topic of girl bullying.

In her latest book, Masterminds and Wingmen: Helping Our Boys Cope with Schoolyard Power, Locker-Room Tests, Girlfriends, and the New Rules of Boy World she ventures into new and exciting territory. But from the perspective of a grown up boy, I think, despite her best intentions, she doesn’t really get the boy world. This is probably because she never was a boy and can only try to understand the internal struggles and experiences of boys from an external perspective. This doesn’t make her effort bad or unimportant . . . but it does limit her reach. For the purposes of this blog, I want to focus on one particular excerpt that I found both ridiculous and potentially damaging.

On p. 87, she wrote:

“It’s important to allow him [your boy] to have a wide range of feelings.  Moms, if he’s feeling so angry that he wants to release his anger by punching a pillow or a punching bag, or going into his room and yelling at the top of his lungs, or playing really loud music, or even playing a violent video game, let him do it.  If he punches the wall, that’s okay too, as long as he isn’t threatening someone else when he’s doing it.  Plus, after he’s calmed down, he can then learn the skill of drywall patching. The bottom line is that a lot of women can be intimidated in the presence of men’s anger (with good reason).  But at the same time, your son needs a healthy outlet to express his anger without feeling like you think he’s a violent, crazy person for having his feelings.”

Let me just say this, “Like OMG. This is like some really gnarly bad advice.”

As you can see, I’m about as good at channeling my inner girl as Wiseman is at channeling her inner boy. To get back to my adult male persona, what I really want to say is that in this short excerpt, Wiseman’s ideas are so limited that I find them disturbing.

Perhaps the worst part is that Wiseman doesn’t seem to understand the basic and crucial difference between emotions and behaviors. It is and should be completely acceptable for all boys and all girls to experience anger. Anger is a natural and inevitable human emotion. But the emotion of anger is not the same as aggressive behavior. The fact is that boys CAN acknowledge and express their anger WITHOUT PUNCHING THINGS. And they SHOULD be expected to NOT PUNCH THINGS.

Let me emphasize this by saying it again: Boys can and should be expected to express their angry emotions without becoming violent or aggressive. It’s absolutely crucial for boys to learn to use their words and to control or inhibit their aggressive behaviors. A big problem with Wiseman’s message is that she’s coaching moms (and other adults) to accept inappropriate and unacceptable aggressive behaviors—from boys. She seems to be advocating the all-American excuse that boys will be boys and so therefore we should tolerate their aggression and not expect anything different. This is an unhelpful and potentially destructive message. Instead, the message from parents and caring adults needs to be: “I accept your angry emotions; but aggressive behavior is unacceptable.”

Part of what Wiseman is suggesting isn’t terrible. The idea of a natural consequence of drywall patching after an unacceptable aggressive outburst is reasonable. And the idea that moms shouldn’t be intimidated in response to their son’s anger or aggression is very important. But there’s a big difference between accepting an emotion and tolerating an aggressive behavior. Boys need to know that punching and destroying things is an unacceptable way to express their anger.

I think one of Wiseman’s limitations is that she’s never experienced anger and aggressive impulses from the inside of a male body.

As for myself:

I remember the last time I punched a wall . . .

I remember the last time I broke down a door . . .

I remember the last time I ripped a cupboard door off its hinges . . .

I also recall the last time I lashed out in anger and used a particularly unacceptable word to describe a woman. And I’m thankful to the person who taught me very clearly and very directly that I was engaging in an unacceptable behavior. It took me one firm but gentle lesson from a caring adult to learn to never use that disparaging word again.

I remember getting laid out as flat as a pancake by a 290 pound offensive tackle at Reser Stadium in 1978. And I remember wanting nothing more than another chance to get him back.

I also remember how I learned to watch my anger instead of acting on it. I remember the lessons my parents taught me. I remember practicing a deep breath and talking with my psychotherapist about my angry rages. I remember learning to deal more constructively with my revenge impulses even though I wanted so badly to give another male a physical pay-back. And I remember NEEDING SOMEONE to set limits on my aggressive behaviors.

It’s not easy for boys to learn to control their behavior. It’s also not easy for boys to learn to talk about anger (rather than acting on it). But this isn’t all about biology and testosterone. It’s also—and perhaps primarily—about the social expectations that most people hold for boys. If we expect and tolerate aggressive behavior as just part of being a boy, then we have very little chance of changing or improving how boys are capable of behaving.

The bottom line for me (and I know this is personalized and not completely unbiased) is that boys need caring and loving adults to raise the bar for them. I needed—and many boys need—higher (not lower) expectations when it comes to dealing with our anger.

My memories (and my counseling and psychotherapy work with boys) inspire my conclusions. Here they are:

IT IS ESSENTIAL for caring and loving adults to actively teach their boys that anger and sadness and fear and guilt and joy are all acceptable and expected emotions.

It’s equally essential for these same caring and loving adults to teach boys that aggressive behavior is NOT ACCEPTABLE.

If we don’t teach boys these lessons, then we’re lowering the bar to the point that we have no right to expect them to behave in civilized and non-violent ways.

And most of us are far better off when boys and men understand and manage their anger—rather than acting on their aggressive impulses.

Please help spread the word that we should expect more (not less or the same old thing) from boys. I know Ms. Wiseman is well-intended, but in this case we need to counter her bad advice with some good ideas.

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What You Missed in Cincinnati: Part II

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

Generating Behavioral Alternatives With an Aggressive Adolescent

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

The transcript below begins 10 minutes into the session.

Boy: He’s gotta learn sometime.

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

Boy: I’ve been thinking a lot.

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

Boy: Kick the shit out of him.

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

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

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

Boy: Yeah, Yeah.

JSF: So, what else?

Boy: I could nark on him.

JSF: Oh.

Boy: Tell the cops or something.

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

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

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

Boy: It’s not gonna happen though.

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

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

JSF: Okay. Talk to him.

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

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

Boy: Yeah. Yeah.

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

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

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

Boy: [This section is censored.]

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

Boy: Someone like . . .

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

Boy: That’s about it. . . .

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

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

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

Boy: That’s a good idea.

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

Boy: Like he has a little dick or something.

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

Boy: Maybe I’ll do all these things.

JSF: Combination.

Boy: Yeah.

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

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

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

  • Decision making
  • Solution implementation and verification

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

What You Missed in Cincinnati

For me, the hardest thing about presenting professional workshops is time management. I want participants to comment, but how can I plan in advance for exactly how long their comments will be? Even worse, how can I accurately estimate the length of my own impromptu moments? It seems obvious that there’s a need for spontaneity. I don’t want to cut off potentially valuable comments from participants . . . and I don’t want to cut off my own creative musings either. Clearly, the clock is my workshop enemy.

For example, how could I know in advance that I would suddenly feel compelled to share a personal dream of mine with 85 of my new Cincinnati counselor friends? Never before had I shared with a workshop audience that 45 years-ago I dreamt I was Felix-the-Cat and then while crossing the road (as Felix), I got hit by a car . . . and died.

But then I woke up and have kept on living.

I like to think that particular disclosure is a perfectly normal thing to do when you’ve got a group of professional counselors to listen to you.

The point was to bust the myth that some teenage client have (and will talk about in counseling) that if they dream they die, it is prophetic and means they’ll die soon in real life also.

And beyond my personal dream disclosure, how would I know that one of the participants would have such passion that he would accept an invitation to come up to the microphone and share a physical relaxation technique that he uses with elementary school students.

These are just two samples of the sort of thing you missed because you weren’t in Cincinnati at the Schiff Center on the Xavier University campus yesterday.

But you also missed the start of the workshop where I decided on the spot that it was just the right time and place for me to open the workshop with a story of the most embarrassing moment in my life. It struck me as an awesome idea at the time . . . and it really was the most embarrassing moment of my life . . . until a few hours later when I shared my Felix-the-Cat dream.

There are always bigger mountains to climb.

You also missed meeting my incredibly gracious hosts from the Greater Cincinnati Counseling Association including, Butch Losey (who’s the most humble and understated guy who should be famous I’ve ever met), Kay Russ (who’s right up there with the most responsible person I’ve ever met), and Brent Richardson (who is as irreverent and insightful as ever), and Robert Wubbolding (who may be on his way to Casablanca to do a week long choice theory/reality therapy workshop by the time I post this and yet took eight hours out of his life to attend the workshop anyway).

So that’s just a little taste of what you missed in Cincinnati.

I’ll bet you wish you were there. I know I’m glad I was.

January is an Excellent Month to Attend Workshops in Cincinnati

Just in case you’re planning to be in or around the Cincinnati area this weekend, the Greater Cincinnati Counseling Association (GCCA) is offering a day and a half of workshops starting on Friday afternoon, January 10 and two workshops with one of my favorite workshop presenters on Saturday, January 11. Here’s the info:

On Friday, January 10, there are two Ethics workshops to choose from:

2:00-5:15

School Counselor Ethics: Case

Discussions and Current Trends

Tanya Ficklin

Or

2:00-5:15

Ethical and Professional Issues:

Therapeutic Alliance Building and

Ethical Considerations When

Working with Children and

Families

Barbara Mahaffey

On Saturday, January 11, I’m doing two separate ½ day workshops:

Tough Kids, Cool Counseling

John Sommers-Flanagan

Saturday 8:45-12:00

Therapy with adolescents can be immensely frustrating or splendidly gratifying. The truth of this statement is so obvious that the supportive reference, at least according to many adolescents is, “Duh!” In this workshop participants will sharpen their therapy skills by viewing and discussing video clips from actual sessions and participating in live demonstrations. Over 20 specific cognitive, emotional, and constructive therapy techniques will be illustrated and/or demonstrated. Examples include acknowledging reality, informal assessment, the affect bridge, therapist spontaneity, early interpretations, asset flooding, externalizing language, and more. Countertransference and multicultural issues will be highlighted.

Suicide Assessment Interviewing

Saturday 1:00-4:15

John Sommers-Flanagan

Freud once said, “By words one person can make another blissfully happy or drive him to despair.” Ironically, traditional adolescent suicide assessment and intervention procedures overemphasize a pathology-based biomedical model that orients adolescents toward despair. In this workshop suicidal crises are reformulated as normal expressions of human suffering and a specific, positive, and practical approach to adolescent suicide assessment interviewing is described. This contemporary adolescent suicide assessment model has a constructive focus, addresses diversity issues, and integrates differential activation theory and Jobes’s approach to Collaborative Assessment and Management of Suicidality. Specific suicide intervention procedures will be described and reformulated.

You can register for these workshops by phone by calling: 513-688-0092

 

The “Extra” Tough Kids, Cool Counseling Workshop Handout

This is the supplementary handout for the Tough Kids, Cool Counseling workshop. It includes more detailed information about all of the techniques covered in the workshop (as well as a few extra). Of course, those interested in EVEN MORE details, should somehow get a hold of a copy of the Tough Kids, Cool Counseling book:  http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=cm_cr_pr_product_top

Tough Kids, Cool Counseling

Supplementary Handout

John Sommers-Flanagan, Ph.D.

University of Montana

John.sf@mso.umt.edu

Johnsommersflanagan.com

“I have lived some thirty years on this planet, and I have yet to hear the first syllable of valuable or even earnest advice from my seniors”   — Henry David Thoreau

The following techniques and strategies are discussed in the workshop. More extensive information is included in the Tough Kids, Cool Counseling (2007) book published by ACA publications and other resources listed in the reference section.

  1.  Acknowledging Reality: Teenagers and some pre-teens are likely to be initially suspicious and mistrustful of adults – especially sneaky, manipulative, authority figures like mental health or school counselorsJ. To decrease distrust, it is important to simply acknowledge reality about the reasons for meeting, about the fact that you’re strangers, and to notice obvious differences between the therapist and teen.
  2. Sharing Referral Information: To gracefully talk about referral information with teens, therapists need to educate referral sources about how this practice will be used. Specifically, referral sources should be trained to give therapists information about clients that is both accurate and positive. If referral information from teachers, parents, or probation officers is especially negative, the therapist should screen and interpret the information so it is not overwhelming or off-putting to young clients.  Simblett (1997), writing from a constructive perspective, suggested that if therapists are planning to share referral information with clients, they should warn and prepare referral sources about such a practice. If not, the referral sources may feel betrayed. Also, when sharing negative information about the client, it’s important for the counselor to have empathy and side with the client’s feelings, while at the same time, not endorsing the negative behaviors. For example, “I can see you’re really mad about your mom telling me all this stuff about you. I don’t blame you for being mad. I think I’d be upset too. It’s hard to have people talking about you, even if they might have good intentions.”
  3. The Affect Bridge and Early Memories: The affect bridge is designed to link current emotions with past emotions. Originally described as a hypnoanalytic technique by John Watkins (1971), the procedure can be used without a trance state to deepen your understanding of the origin and power of your client’s problematic affective states. The technique is simple and direct. For example, you might say: “You’re doing a great job telling me about some recent things that really make you mad. Now, tell me about an earlier time, when you were younger, when you felt similar feelings.” This technique or prompt will often elicit early memories that can then be used, similar to Adler’s early recollection method, to understand the client’s schema, cognitive map, or lifestyle.
  4. Reflection of Emotions: Emotional reflections or reflection of feeling (Rogers, 1942, 1961), are very important in counseling adolescents. This is because most youth are just learning about themselves and calibrating their emotional selves. Emotional reflections serve at least a two-fold purpose: (a) they provide youth a chance to see/hear themselves in an emotional mirror, and (b) they provide youth with a chance to tell the therapist that he or she has it all wrong (a corrective function). If the therapist begins noticing that he or she is consistently getting the emotional and content reflections incorrect with a given client, an effort at emotional repair is warranted. This simply involves apologizing for being incorrect, appreciating the client’s efforts to correct the therapist and a statement of commitment to continue trying.
  5. Coping with Countertransference: Research has shown that our countertransference reactions can teach us about ourselves, our underlying conflicts, and our clients (Betan, Heim, Conklin, & Westen, 2005; Mohr, Gelso, & Hill, 2005). For example, based on a survey of 181 psychiatrists and clinical psychologists, Betan et al., reported “patients not only elicit idiosyncratic responses from particular clinicians (based on the clinician’s history and the interaction of the patient’s and the clinician’s dynamics) but also elicit what we might call average expectable countertransference responses, which likely resemble responses by other significant people in the patient’s life” (p. 895). Countertransference is now widely considered a natural phenomenon and useful source of information that can contribute to counseling process and outcome (Luborsky, 2006). In fact, clinicians from various theoretical orientations have historically acknowledged the reality of countertransference. Speaking from a behavioral perspective, Goldfried and Davison (1976), the authors of Clinical Behavior Therapy, offered the following advice: “The therapist should continually observe his own behavior and emotional reactions, and question what the client may have done to bring about such reactions” (p. 58). Similarly, Beitman (1983) suggested that even technique-oriented counselors may fall prey to countertransference. He believes that “any technique may be used in the service of avoidance of countertransference awareness” (p. 83). In other words, clinicians may repetitively apply a particular therapeutic technique to their clients (e.g., progressive muscle relaxation, mental imagery, or thought stopping) without realizing they are applying the techniques to address their own needs, rather than the needs of their clients. There are many moments to reflect on how countertransference dynamics might affect the counseling process during the workshop.
  6. Exploring Attributions and Core Beliefs and Constructing Alternative, Strength-Based Theories: It’s a funny thing that most people, not just adolescents, seem to automatically adopt and hang onto negative core beliefs about the self. In the workshop video clip, you will see Rita SF as she gently helps her client explore his own beliefs and attributions. She then, using rational explanation, nudges him toward a shift in those beliefs. Interestingly, after she makes her intervention, the client then begins speaking in a different—and perhaps more positive—way about his primary conflict. Of course, we know that it is very challenging to convince clients of new, strength-based attributions about the self. Often clients take a step or two forward and then a step or two back—because it is often tremendously difficult to begin believing in a new and better self.
  7. What’s Good About You? This procedure provides an opportunity for a rich interpersonal interaction with teenage clients. It also generates useful information regarding child/adolescent self-esteem. I like to initially, introduce it as a “game” with specific rules: “I want to play a game with you. I’m going to ask you the same question 10 times. The only rule is that you cannot answer the question with the same answer twice. In other words, I’ll ask you the same question 10 times, but you have to give me 10 different answers.” When playing this game therapists simply ask their client, “What’s good about you?” (while writing down the responses), following each response with “Thank you” and a smile. If the client responds with “I don’t know” the therapist simply writes down the response the first time, but if the client uses “I don’t know” (or any response) a second time, the therapist reminds the client, in a light and possibly humorous manner, that he or she can use answers only one time. As with all techniques, this should be used with client consent or agreement. If the client is uncomfortable and does not want to proceed, his or her reluctance should be respected. In some cases, there may be cultural reasons (i.e., a client has a collectivist cultural background) for refusing to do this activity.
  8. Interpersonal Simulations: In this procedure the counselor provides the teen with an interpersonal scenario to solve. This technique is based on the fact that it is often easier for young people to openly discuss how they feel about impersonal situations that it is for them to openly discuss their own situations. The technique can be used for either assessment or intervention purposes and can be initiated as a generic question or “survey” that you’re using with teens or as a personal story/situation that you need help with. For example, you might say, “I’ve been doing a sort of survey with other teens and I’m interested in your opinion. Let’s say your parents are going to be out of town for the weekend. As they’re leaving, they tell you they trust you to take care of yourself and they trust you not to have a big party at home while they’re gone. After they left, what would you do?” Then, depending upon the youth’s response to this situation, you can ask many follow-up questions: “Would you have a party?, How many people would you invite? What if you didn’t want to have a party, but the rumor that your parents were gone got out and people started pressuring you? If you had a party, would you have alcohol? How about drugs? If your parents ask you if you had a party when they get back into town, how would you respond? Would you lie? How would that feel?” Finally, at the end you can ask the teen if he/she is interested in hearing about how others have responded to the questions/survey.
  9. Asset Flooding: With many teens who engage in challenging behaviors, communication breaks down because of how badly they are feeling about themselves. Consequently, communication and cooperation can be enhanced when the counselor simply stops and reflects on the teen’s positive qualities. Of course, you need to have several positive attributes available in your mind before beginning this intervention. You can proceed by saying something like: “You know, I was just thinking about how I think you have all sorts of good qualities. . . like you’re always on time, you hang in there and keep attending your classes, even though I know sometimes you don’t really like them. . . that tells me you’ve got courage, courage to face unpleasant things. . . I also like your sense of humor. . . and. . .”
  10. Generating Behavioral Alternatives: Frequently teens become focused on one or two maladaptive behavioral responses to challenging situations. For example, they may either yell at their teacher or run out of class, but they seem unable or unwilling to try a more moderate response such as discussing their conflict or problem with the teacher in order to seek resolution. In the workshop, I will discuss a counseling session illustrating a modified behavioral alternatives procedure designed to reduce behavioral aggression. The transcript for this session is included at the end of this handout.
  11. Using Riddles and Games: In the Tough Kids book we describe a number of interesting activities that therapists can use with young clients. One strategy is to initiate some “mental set” activities with your client. For example, you might say, “I’d like you to say the word ‘ten’ ten times and I’ll count.” The client then says, “10, 10, 10. . .” and at the end you say, “Okay, what are aluminum cans made of?” Often the youth will say, “TIN” which of course the wrong answer, because the correct answer is aluminum. After doing this you can then discuss how our minds sometimes will misinterpret things which is why we should always think twice before reacting.
  12. Food and Mood: Using food with young clients can help put them in a better mood and if they’re in a better mood, generally counseling proceeds a bit more smoothly. Our food guidelines include: (a) we try to keep relatively healthy snacks available (e.g., sugarless gum, juice, herbal tea, granola bars, carrots, grapes); (b) we don’t always offer something to eat (that usually depends on the time of day and the client’s hunger state), but we usually offer something to drink at the beginning of each session; (c) occasionally kids will overstep boundaries and ask for more and more food and sometimes they begin to expect treats, or even to criticize their counselor for the types of treats available—but of course, such behavior simply provides the astute professional with more material for exploration and interpretation. Perhaps children who act out with respect to food lack social inhibition—or are not eating well—or are impulsive—or are hungry for attention. Whatever the case, food items provide opportunity for discussion, feedback, and behavior change. And of course, food almost always improves mood.
  13. A Multicultural Opening: In the video clip with John and Michael, John begins by noting differences between the two of them and then asking Michael to share some of his personal experiences about being an African American gang member. This opening comes dangerously close to an inappropriate request – for Michael to educate John about his culture and lifestyle. However, because John emphasizes his interest in Michael’s personal experiences, the opening may be appropriate – but you can be the judge.
  14. Noticing Process in Counseling: When there’s a clear pattern that begins to manifest itself in the counseling session, it’s best to acknowledge that pattern. This may be a pattern, as in the John-Michael clip, where the counselor is not “getting it” or having trouble accurately listening to the client. Or, it may be a situation where the counselor is trying to convince the student of something, but the student is resisting. In these situations, it’s recommended that the counselor acknowledge the process reality in the session.
  15. Four Forms of Relaxation: Young clients are often resistant to relaxation techniques. During the workshop, four approaches to helping teens relax and self-soothe will be demonstrated. Generally, we recommend using all four approaches in a single session with young clients. These approaches include: (a) deep breathing; (b) visualization; (c) autogenic training; and (d) progressive muscle relaxation. The offering of these relaxation approaches in this particular order is designed to help young clients decide which approach will work best for them and to end on a light note that facilitates a positive mood.
  16. Cognitive Storytelling: Most teens, especially elementary teens, have a natural interest in stories and storytelling. In addition to using stories as metaphors, it can be useful for counselors to incorporate storytelling procedures that illustrate cognitive and behavior principles into counseling. The road rage, monkey surgery, or cherry story will be shared with participants in this workshop.
  17. Respect, Liking, and Interest: In person-centered counseling, it’s not the counselor’s microskills of listening, etc., that facilitate change, but instead, it is the therapist’s attitude of congruence, unconditional positive regard, and empathic understanding. Similarly, spontaneity and humor with young clients should be avoided unless you, as a therapist, experience the attitudes and feelings of respect, liking, and interest for the teen. There is no substitute for this therapeutic foundation. It must be genuine because teens are especially adept at detecting phoniness in adults. You should work toward feeling deep inside that there is no other place you would rather be than sitting in the room and listening and talking with your young client.
  18. Early Interpretation: In the Adlerian counseling spirit, early interpretations with adolescents are quick observations of the teen’s cognitive style or lifestyle. These interpretations are not particularly deep, but instead designed to provide insight into the surface dynamics with which the teen is struggling. There are two examples of early interpretations given in the workshop. First, I observe with Sean that he is “perfectionistic” which then allows exploration of how his perfectionism is affecting his anger. Second, I share with Meagan the observation that she seems very sensitive to “injustice,” which we then explore together. Early interpretations provide an initial formulation upon which both client and therapist can work.
  19. Self-Rating Strategies: There are many different rating strategies that can be used to facilitate the counseling process. The scaling question from the solution-focused framework can be helpful for identifying what it would look like if small amounts of change occurred. In the session with Sean, John tries using a 0-100 scale combined with a grading system to uncover Sean’s maladaptive thoughts.
  20. Using a Role-Reversal: Role reversals with teens can be interesting and sometimes fun. In the workshop example, I ask Sean to be my “counselor.” Sean responds by taking his role seriously and I surprise myself somewhat by taking my role very seriously (which may be, to some degree, a manifestation of countertransference). The purpose of role reversals is twofold. First, it helps teens work on the crucial cognitive task of perspective taking. Second, it can help the teen have more empathy for himself or herself.
  21. Self Disclosure: Self disclosure is risky, but necessary when working with teens. Most of the time, they don’t really want to hear long, boring stories about the therapist and so those stories should be avoided. Instead, short stories that serve to deepen the connection or to make a therapeutic point are recommended.
  22. The Fool in the Ring and Satanic Golden Rule: This technique is derived from Eva Feindler’s work with aggressive youth. It involves using the “Fool in the Ring” metaphor for helping youth see that they are giving up freedom when they react (predictably) and aggressively toward individuals who provoke them. The therapist draws a picture of two stick-figures engaging in a conflict and brainstorms how the young person being provoked might respond to conflict situations without engaging in retaliation and without engaging in behaviors likely to perpetuate aggression and result in negative consequences. Additionally, the message behind this metaphor and brainstorming activity is further developed by discussing the Satanic Golden Rule. In the end, youth are encouraged to use a more thoughtful and intentional response to provocation – instead of simply responding to aggression.
  23. Reconstructing the Client’s Story About the Self (Questioning the Main Maladaptive Narrative): One of the most powerful factors influencing human behavior is the self-story. Most teens spend mental time telling themselves about themselves. This inner story or narrative usually includes a number of old, negative, and maladaptive judgments about the self. For example, many teens will make claims like, “I have a terrible temper. I just blow my top if anybody gets on my case.” It’s important for therapists to question young clients when they make definitive claims about having a negative trait. In particular, using the questions: “Have you ever performed in a play?” and “How did you remember your lines?” can be used to point out to teens that they have been practicing the same “lines” about themselves for years and that it might be time to start learning and practicing some new and different lines about themselves.
  24. Alternatives to Suicide: This technique is virtually identical to generating behavioral alternatives except it’s used with young clients who are suicidal. It involves simply but compassionately listing the client’s options in life, including suicide. Then, after a list is jointly generated, the client ranks his/her top preferences. This process provides both assessment and intervention data.
  25. Neo-Dissociation: Adolescence is a time of ambivalence. Although adolescents often express very strong feelings, they also usually have underlying feelings that may even be contradictory to the strong feelings they are expressing. This technique is designed to capitalize on the teen’s underlying, prosocial thoughts and impulses. If a teen adamantly emphasizes that s/he doesn’t care about something, after you have empathized with his/her apathy, then you can explore for underlying feelings of caring or concern. For example, if the teen says, “I don’t care about math. It sucks. The teacher sucks. Anybody who likes math is a nerd. So I don’t care if I flunk,” you can respond with empathy: “Okay. I totally hear you. You hate math and you totally don’t care if you flunk.” Then, you can explore using the neo-dissociative technique by saying: “I’m guessing that even though you really don’t care about your math grade, there might be a part of you that cares just a little bit. I’d like to talk to that part of you for a minute.”
  26. Note-Passing: This technique can be used with students who have shut down and require a new communication modality. It involves the counselor noticing the “shut down” state and then writing a kind and supportive note to the student, folding it, and handing it over. It’s often hard for students to resist reading a handwritten passed note. Sometimes they’ll speak in response, other times they’ll write a note back, and sometimes they’ll continue in their shut down state. Drawing or artwork can also function as an alternative communication modality.

 References

 Berman, A. L., Jobes, D. A., & Silverman, M. (2006). Adolescent suicide: Assessment and intervention. (2nd ed.). Washington, D.C.: American Psychological Association.

Bernstein, N. (1996). Treating the unmanageable adolescent. Northvale, NJ: Jason Aronson.

Betan, E., Heim, A.K., Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162 (5), 890 – 898.

Castro-Blanco, D., & Karver, M. S. (2010). Elusive alliance: Treatment engagement strategies with high-risk adolescents. Washington, DC: American Psychological Association.

Creed, T. A., & Kendall, P. C. (2005). Therapist alliance-building behavior within a cognitive– behavioral treatment for anxiety in youth. Journal of Consulting and Clinical Psychology, 73, 498-505.

de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.

Feindler, E. (1986). Adolescent anger control. New York: Pergamon Press.

Glasser, W. (2002). Unhappy teens. New York: HarperCollins.

Hanna, F. J., Hanna, C. A., & Keys, S. G. (1999). Fifty strategies for counseling defiant, aggressive adolescents: Reaching, accepting, and relating. Journal of Counseling & Development, 77(4), 395-404.

Hawley, K. M., & Garland, A. F. (2008). Working alliance in adolescent outpatient therapy: Youth, parent and therapist reports and associations with therapy outcomes. Child & Youth Care Forum 37(2), 59-74

Juhnke, G. A., Granello, P. F., Granello, D. H. (2011). Suicide, self-injury, and violence in the schools: assessment, prevention, and intervention strategies. Hoboken, NJ: Wiley.

Kazdin, A. E. (2008). The Kazdin method for parenting the defiant child: With no pills, no therapy, no contest of wills. Boston, MA: Houghton Mifflin Company.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.

Mohr, J. J., Gelso, C. J., & Hill, C. E. (2005). Client and counselor trainee attachment as predictors of session evaluation and countertransference behavior in first counseling sessions. Journal of Counseling Psychology, 52 (3), 298–309.

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

Shea, S. C. (1999). The practical art of suicide assessment. New York: Wiley.

Sommers-Flanagan, J., & Bequette, T. (2013). The initial interview with adolescents. Journal of Contemporary Psychotherapy, 43(1), 13-22.

Sommers-Flanagan, J., Richardson, B.G., & Sommers-Flanagan, R. (2011). A multi-theoretical, developmental, and evidence-based approach for understanding and managing adolescent resistance to psychotherapy. Journal of Contemporary Psychotherapy, 41, 69-80.

Sommers-Flanagan, J., & Campbell, D.G. (2009). Psychotherapy and (or) medications for depression in youth? An evidence-based review with recommendations for treatment. Journal of Contemporary Psychotherapy, 32,111-120.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2007). Tough kids, cool counseling: User-friendly approaches with challenging youth (2nd ed.). Alexandria, VA: American Counseling Association.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2014). Clinical interviewing. (5th ed.). New York: Wiley.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2012). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques. New York: Wiley.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2004). The challenge of counseling teens: Counselor behaviors that reduce resistance and facilitate connection. [Videotape]. North Amerst, MA: Microtraining Associates.

The TADS Team. (2007). The treatment for adolescents with depression study (TADS): Long term effectiveness and safety outcomes. Archives of General Psychiatry, 64(10), 1132-1144.

The TADS Team. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for adolescents with depression study (TADS) randomized controlled trial. JAMA: Journal of the American Medical Association, 292(7), 807-820.

Turner, E.H., Matthews, A.M., Linardatos, E., Tell, R.A., & Rosenthal, R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy. The New England Journal of Medicine, 358, 252-360.

United States Food and Drug Administration. (2007). FDA proposes new warnings about suicidal thinking, behavior in young adults who take antidepressant medications. Retrieved January 10, 2008, from http://www.fda.gov/bbs/topics/NEWS/2007/NEW01624.html

Watkins, J. G. (1971). The affect bridge: A hypnoanalytic technique. International Journal of Clinical and Experimental Hypnosis, 19, 21-27.

Weisz, J., & Kazdin, A. E. (2010). Evidence-based psychotherapies for children and adolescents (2nd ed.). New York: Guilford.

Willock, B. (1986). Narcissistic vulnerability in the hyper-aggressive child: The disregarded (unloved, uncared-for) self. Psychoanalytic Psychology, 3, 59-80.

Willock, B. (1987). The devalued (unloved, repugnant) self: A second facet of narcissistic vulnerability in the aggressive, conduct-disordered child. Psychoanalytic Psychology, 4, 219-240.

If you have questions about this handout, or are interested in having John SF conduct a workshop or keynote for your organization, please contact John at: 406-243-4263 or john.sf@mso.umt.edu. You may reproduce this handout to share with your colleagues if you like, but please provide an appropriate citation. For additional free materials related to this workshop and other topics, go to John’s Blog at: johnsommersflanagan.com

Electronic Classrooms of Tomorrow — Powerpoint slides for “How to Listen. . .”

This coming Thursday and Friday I’ll be in Columbus, OH for the Electronic Classrooms of Tomorrow (ECOT) conference. For Thursday, I’m presenting several break-out sessions on “How to Listen so Parents will Talk and Talk so Parents will Listen.” The powerpoints for that presentation are here:

How to Listen for ECOT

On Friday I doing an all-day workshop with the ECOT counselors with a little of everything (Tough Kids, Cool Counseling, Suicide Assessment/Intervention, and Working with Parents). Here are the ppts for Friday’s workshop:

ETOC TKCC No Tunes

Thanks very much to Emma Baucher who has been incredibly helpful in arranging this.

 

Reformulating Clinical Depression: The Social-Psycho-Bio Model

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

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

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

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

A Social-Psycho-Bio Model of Clinical Depression

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

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

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

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

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

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

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

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

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

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

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

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