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
John Sommers-Flanagan, Ph.D.
University of Montana
“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.
- 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.
- 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.”
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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. . .”
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.”
- 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.
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 firstname.lastname@example.org. 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