Building a Therapeutic Relationship with Parents: Part III – Collaboration

Collaboration, as an attitude, requires that at least to some extent, parenting professionals come from a position of “not knowing” (Anderson, 1993; Anderson & Goolishian, 1992). As Anderson (1993) stated: “The not knowing position is empathic and is most often characterized by questions that come from an honest continuous therapeutic posture of not understanding too quickly” (p. 331).

[This excerpt is from How to Listen so Parents will Talk . . . http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_5?ie=UTF8&qid=1368845509&sr=1-5%5D

Not knowing requires professionals to resist the ubiquitous impulse to be all-knowing experts. Resisting the impulse to demonstrate one’s expertise is especially important when initially meeting with and working with parents.

It can be very difficult for parenting professionals to  establish and maintain a collaborative attitude. This is partly because human services providers who work with parents also need to be experts and must demonstrate their expertise. Similar to radical acceptance, collaboration between professionals and parents is a dialectic where the professional embraces both the parents’ expertness and his or her own expertise.

Some writers have emphasized that true collaboration between professionals and parents requires a form of leaderlessness (Brown, Pryzwansky, & Schulte, 2006; Kampwirth, 2006). In contrast, our position is that professionals who work with parents can and should bring the following knowledge, skills, and expertise to the consulting office:

  • How to lead or direct a counseling or consultation meeting
  • How to quickly form collaborative relationships and a working alliance with parents
  • Knowledge of what contemporary research says about child development and child psychopathology
  • A wide range of theoretically diverse and research-informed strategies and interventions to use with parents
  • A wide range of theoretically diverse and research-informed strategies and techniques for parents to implement with their children

At the same time, parents are also experts who bring the following knowledge and expertise into your office:

  • Their own personal memories and experiences of being parented
  • Knowledge and experience of their children’s unique temperament and behavior patterns
  • Awareness of their personal parenting style and efforts to parent more competently
  • Knowledge of their existing parenting strategies as well as the history of many other parenting ideas they have tried and found to be more or less helpful
  • An understanding of their limits and abilities to use new or different parenting strategies and techniques

In a very practical sense, it would be inappropriate (and probably ineffective) to ignore the fact that parents come to human services professionals expecting advice and guidance about how to be and become better parents. This is the frame from which virtually all parenting interventions flow. Consequently, if the consultant or therapist behaves too much like an equal and doesn’t act at all like an expert who offers concrete and straightforward advice, the meeting will likely fail because the basic assumption that the therapist is a helpful expert will be violated.

On the other hand, for many reasons, parents are in a vulnerable state and consequently, if they feel their parenting consultant  is acting like a judgmental or condescending expert, they will usually become defensive and antagonistic. To counter this possibility, the professional  needs to hold a collaborative attitude that honors the parents’ knowledge and experience. This collaborative attitude will help parents see themselves as respected and relatively equal partners in the therapeutic and/or educational consultation process.

Overall, the model we describe in this book (How to Listen so Parents will Talk and Talk so Parents will Listen) emphasizes that, from a position of respect, interest, and curiosity, parenting consultants, counselors, and therapists work to quickly establish a partnership with parents. When therapeutic or educational work with parents is most successful, parents will likely perceive you as an empathic, accepting, and collaborative expert willing to offer a wide range of theoretically divergent, practical, meaningful, and simple suggestions for how to parent more effectively.

 

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This is Why I Have a Blog (in 212 words)

While visiting my parents recently an older gentleman on a scooter rode up and greeted me. We had a friendly conversation within the confines of my parents’ gated community. He said his dog had mistaken me for his son. I looked down and saw a small dog or large rodent sniffing my shoes. Then his son emerged from the house. The son was quite animated as he was taking a smoke break from his online gaming.

The next morning I saw the son again. He was pedaling his bicycle slowly, smoking, and looking rather like a homeless man. He didn’t seem to recognize me.

I found myself thinking I felt reassured that the older gentleman’s very small dog obviously had a very small brain.

But who am I to say whom or what I do or do not resemble. Maybe I’m more like a gaming and smoking homeless man on the street than I think. After all, I can’t see myself very well anyway.

This is the nature of my internal conversations. A swing towards the too critical and too judgmental followed by a swing back toward self-critique.

This might be why B.F. Skinner suggested that thinking is irrelevant.

This also might be why I have a blog and not a dog.

Your Life is Now: Trapper Creek Reflections

The Road

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

********************

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

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

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

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

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

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

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

Your Life is Now

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

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

Your life is now

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

Your life is now

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

Your life is now

The second young woman was equally impressive.

In this undiscovered moment

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

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

Lift your head up above the crowd

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

We could shake this world

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

If you would only show us how

Thank you Trapper Creek

Thank you fine young women and men

Thank you nurses and doctor and interns and staff

Thank you deer and Bitterroot drivers

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

 Your life is now

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Building a Therapeutic Relationship with Parents: Part I

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

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

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

Empathy for Parents and Parenting

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

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

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

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

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

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

Part II of this three part blog post continues tomorrow.

The Return of Mother’s Little Helper . . .

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

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

Here’s the piece. Sarcasm included.

The Return of Mother’s Little Helper

            Mother’s little helper is back.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

            Throughout the room, eyes began to roll.

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

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

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

            “Like what?” I asked.

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

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

The Love Reframe

 

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

 

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

 

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

 

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

 

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

Author, Speaker, University of Montana Professor