Tag Archives: adolescents

Clinical Interviewing, Suicide Assessment and Intervention, Tough Kids Cool Counseling

Resources from my American Counseling Association Conference Presentations

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Last week I had the honor of presenting three times at the American Counseling Association meeting in Atlanta. Today, I’m posting the Abstracts and Powerpoints from those presentations, just in case someone might find the information useful.

On Friday, April 8: The way of the humanist: Illuminating the path from suicide to wellness. Invited presentation on behalf of the Association for Humanistic Counseling.

At this moment, counselors are hearing more distress, anxiety, and suicidal ideation than ever before. In response, we are called to resonate with our clients’ distress. On behalf of the Association for Humanistic Counseling, John Sommers-Flanagan will describe how humanistic principles of acceptance and empathy can paradoxically prepare clients to embrace wellness interventions. Participants will learn five evidence-based happiness strategies to use with their clients and with themselves.

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Also, on Friday, April 8: Using a strengths-based approach to suicide assessment and treatment in your counseling practice. Invited presentation on behalf of ACA Publications.

Most counselors agree: no clinical task is more stressful than suicide assessment and treatment planning. When working with people who are suicidal, it’s all-too-easy for counselors to over-focus on psychopathology and experience feelings of hopelessness and helplessness. However, framing suicidal ideation as an unparalleled opportunity to help alleviate your client’s deep psychological pain, and embracing a strengths-based orientation, you can relieve some of your own anxiety. This practice-oriented education session includes an overview of strengths-based principles for suicide assessment and treatment.

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On Saturday, April 9, Being seen, being heard: Strategies for working with adolescents in the age of Tik Tok. Educational presentation (with Chinwe Williams).

Counseling and connecting with adolescents can be difficult. In this educational session, we will present six strategies for connecting with and facilitating change among adolescents. For each strategy, the co‐presenters, coming from different cultural and generational perspectives, will engage each other and participants in a discussion of challenges likely to emerge when counseling adolescents. Social media influences, self‐disclosure, and handling adolescents’ questions will be emphasized.

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Thanks for reading. I hope some of these resources are helpful to you in your work.

JSF

Parenting, Personal Reflections, Tough Kids Cool Counseling

Interested in Exercise for Treating Depression in Adolescents? Check out the DATE study!

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Half Marathon 2019

Common sense, clinical intuition, non-experimental research studies, and most sentient beings all support the likelihood that physical exercise can reduce depressive symptoms.

But, to the best of my knowledge, only one, very small, randomized controlled study of exercise for treating major depressive disorder in youth has ever been conducted. This study was nicknamed the DATE study (the Depression in Adolescence Treated with Exercise study by Hughes, Barnes, Barnes, DeFina, Nakonezny, & Emslie, and published in 2013 in a journal called, Mental Health and Physical Activity).

A brief review of the DATE study provides a glimpse into the potential of exercise as an intervention for treating depression in youth.

The DATE study randomized youth ages 12 – 18 years into an aerobic/cardio group (n = 16) vs. a stretching group (n =14). Although participants exercised independently and were given a variety of exercise alternatives (they could use Wii or Jazzercize, that’s right Jazzercize), both groups were involved in 12 weeks of rigorously monitored three times weekly exercise treatment protocols.

The results were statistically and clinically significant, with the aerobic condition showing remarkably fast responses and achieving a 100% response rate (86% complete depression remission). The stretching group improved more slowly, but also had a significant positive response (67% clinical response rate; 50% complete depression remission).

Now you might be thinking, that sounds pretty good, but how do those results compare with response rates from established medical treatments, like Prozac?

The authors shared that information. They reported that documented response rates in comparable fluoxetine (Prozac) studies with youth, showed, on average, about a 52% (Prozac) and 37% (placebo) response rate. Just to be clear, let’s put those results in order of which treatment looks best:

  1. Aerobic Exercise = 100% response rate
  2. Stretching = 67% response rate
  3. Prozac = 52% response rate
  4. Placebo – 37% response rate

But the authors didn’t stop there.

They noted that although Prozac shows beneficial treatment effects, clients who take Prozac and other antidepressants commonly experience uncomfortable side effects and occasional health-threatening adverse events. How do you suppose the exercise and stretch groups compared?

No big surprise here: They experienced ZERO side effects and ZERO adverse events.

In summary, the DATE study authors reported that, compared to antidepressant medication treatment with adolescents, exercise resulted in (a) a faster response rate, (b) a better response rate, (c) fewer relapses (n = 0) at six and 12 month follow-ups, and (d) zero side effects or adverse events (Hughes et al., 2103).

But here’s the kicker. Who exactly were these researchers?

This is my favorite part. The researchers were extremely high level and prestigious academics who primarily conduct pharmaceutical research. One of them was the guy responsible for the clinical studies that led to FDA approval of Prozac for treating youth with depression (Graham Emslie). The two biggest names on the study have repeatedly been funded by Eli Lilly, GlaxoSmithKline, Pfizer, and many more. The DATE study was funded by NIH.

Sadly, the DATE study hasn’t been replicated. I can’t find any new RCTs on exercise for  depression among adolescents. When I told this to Rita, she just quipped, “That’s probably because the authors were murdered by pharmaceutical companies in some back alley.”

I hope not. Because, to summarize, the DATE study supports the systematic use of exercise in youth with depressive symptoms OVER and INSTEAD OF antidepressants.

Who knew?

Just about everyone.

Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Multicultural, Therapy with Adolescents

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

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This is a rough preview of a section from the 6th edition Clinical Interviewing. As always, your thoughts and feedback are welcome.

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

Research on how to practice with culturally diverse youth is especially sparse. To make matters more complex, youth culture is already substantially different from adult culture. This means that if you’re different from young clients on traditional minority variables, you’ll be experiencing a double dose of the cultural divide. These complications led one writer to title an article “A knot in the gut” to describe the palpable transference and countertransference that can arise when working with race, ethnicity, and social class in adolescents (Levy-Warren, 2014).

To help reduce the size of the knot in your gut, we’ve developed a simple research- and common-sense list to guide your work with culturally diverse youth (Bhola & Kapur, 2013; Norton, 2011; Shirk, Karver, & Brown, 2011; Villalba, 2007):

1. Use the interpersonal skills (e.g., empathy, genuineness, respect) that are known to work well with adult minority group members. Keep in mind that interpersonal respect is an especially salient driver in smoothing out intercultural relationships.

2. Find ways to show genuine interest in your young clients, while also focusing on their assets or strengths.

3. Treat the meeting, greeting, and first session with freshness and eagerness. There’s evidence that young clients find less experienced therapists easier to form an alliance with.

4. Use a genuine and clear purpose statement. It should capture your “raison d’etre” (your reason for being in the room). We like a purpose statement that’s direct and has intrinsic limits built in. For example: “My goal is to help you achieve your goals . . . just as long as your goals are legal and healthy.” One nice thing about this purpose statement is that sometimes young clients think the “legal and healthy” limitations are funny.

5. Don’t use a standardized approach to always talking with youth about your cultural differences. Instead, wait for an opening that naturally springs up from your interactions. For example, when a teen says something like, “I don’t think you get what I’m saying” it’s a natural opening to talk about how you probably don’t get what the youth is saying. Then you can discuss some of your differences as well as you’re desire to understand as much as you can. For example: “You’re right. I probably don’t get you very well. It’s obvious that I’m way older than you and I’m not a Native American. But I’d like to understand you better and I hope you’ll be willing to help me understand you better. Then, in the end, you can tell me how much I get you and how much I don’t get you.”

6. Provide clear explanations of your procedure and rationale and then linger on those explanations as needed. If young clients don’t understand the point of what you’re doing, they’re less likely to engage.

7. Be patient with your clients; research with young clients and diverse clients indicate that alliance-building (and trust) takes extra time and won’t necessarily happen during an initial session

8. Be patient with yourself; it may take time for you to feel empathy for young clients who engage in behaviors outside your comfort zone (e.g., cutting)

I hope these ideas can help you make connections with youth from other cultures. The BIG summary is to BE GENUINE and BE RESPECTFUL. Nearly everything else flows from there.

Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

Resistance Busters: How to Work Effectively with Teens who Resist Counseling

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Young clients or students and their parents will sometimes be immediately resistant to your efforts to help them change. I don’t mean this in the old-fashioned psychoanalytic form of resistance that blames clients. I mean this as a natural resistance to change. I think we’ve all felt it. Someone has some helpful advice and we feel immediately disinclined to listen and even less inclined to follow the advice. I remember this happening with my father—even when he wanted to tell me something about sports. Of course, he knew a TON more about sports than I did, but logic was not the issue. When it comes to relationships and influencing people, logic is rarely relevant.

If we can buy into using the word resistance—despite the fact that Steve de Shazer buried it in his backyard and had a funeral for it, we would be likely to conclude that resistance behaviors are especially prominent among youth who view their presence in therapy as involuntary. Think of school, court, or parent referred children. Below, in an effort to capture what happens in these situations, Rita and I came up with what we call common resistance styles. Again, the point is not to blame clients or students; after all, they usually come into counseling or therapy with a history that makes their resistance totally natural. Besides, why should we expect them to pop into a therapist’s office and suddenly experience trust and share their deepest feelings.

In combination with these so-called resistance styles, we’ve also developed a range of possible therapeutic responses. To be with de Shazer’s (1985) solution-focused model and because they constitute a first best guess regarding how to respond to these particular resistance styles, we refer to these responses as “formula responses.” Keep in mind that if one formula response is ineffective, an alternative one may be used to reduce and manage this pesky resistance-like behavior.

Resistance Style: Externalizer/Blamer
This young person quickly blames everyone and everything for his or her problems. S/he may feel persecuted; there also may be evidence supporting his/her persecutory thoughts and feelings. Alternatively, the youth may simply have trouble accepting personal responsibility.

SAMPLE STATEMENT: “I would never have flunked science if it weren’t for my teacher. He sucks big-time.”

Formula Responses: One key to responding to this youth is to blatantly side with his or her affect. In the early stages, confrontation with this type of youth is generally ill-advised. For example, Bernstein (1996) states: “Despite a lack of evidence to back up their arguments, we listen carefully without passing judgment” (p. 45). The blamer is sometimes so hypersensitive to criticism that he sees it coming a mile away. Therefore, especially at the outset of therapy, therapists should be cautious about providing criticism or negative feedback. As the client blames others be sure to grunt and moan and say things like, “Oh yeah, I hate it when teachers aren’t fair.” or just use standard person-centered reflections, “You’re saying that being around your teacher really sucks . . .it feels real bad.”

Resistance Style: The Silent Youth
This youth may refuse to speak or may boldly claim that she doesn’t have to talk to you. This youth may have strong needs for power and control and/or may be afraid of what she might say during counseling.

SAMPLE STATEMENT: “I don’t have to talk to you. And you can’t make me.”

Formula Responses: For the completely silent youth who appears to be stonewalling, it may be useful to use a combination of youth-centered reflection of feeling/content and self-disclosure or forced teaming. For example, you might say: “Seems like you really don’t want to be here and you also really don’t want me to know anything about you.” And/or: “If I were you, I wouldn’t trust me either. After all, you were sent here by people you don’t trust and so you probably think I’m on their side. I’d like to prove I’m not on their side, but the only way we can really shock your parents (or probation officer) is by you talking with me and then you and I teaming up to help you have more control over your life.” In the case where the client boldly claims that she does not have to talk with you, it can be helpful to strongly agree with the youth’s assertion (and then simply inquire as to what has been happening in the youth’s life.: “You are absolutely right. You ARE totally in control over whether you talk with me and how much you talk with me.” Then, after a short pause say, “Now, what do you want to talk about?” Sometimes acknowledging the youth’s power and control can decrease his/her need for it.

Resistance Style: The Denier
This is the youth who Repeatedly says: “I’m fine” or “I don’t know” when neither statement is likely to be the truth. These youths can be especially frustrating to therapists because whatever life circumstances that led the youth to therapy are clearly difficult and progress might be made if the youth would admit to having problems. Unfortunately, these youths may have such fragile self-esteem that admitting that any problems are occurring in their lives is very threatening.

SAMPLE STATEMENT: “I’m fine, I don’t have any problems.”

Formula Responses: With youth who say, “I’m fine” we suggest one of two possible formula responses. First, you might say: “If you’re fine, then somebody in your life must not be fine, otherwise, you wouldn’t be here. So, tell me about who forced you to come and what his or her problems are?” The purpose of this statement is to get youths to at least become “blamers” so that you can side with the affect and start building rapport. Second, Bernstein (1996) suggests a statement similar to the following: “You may be right and you may be fine, but if you don’t talk with me about your life, I’ll never know whether you’re fine or not.” Suggested formula responses to “I don’t know” include: “Okay, then tell me something you do know about this problem” or “Tell me what you might say if you did know” or “Boy, it sounds like there are lots of things about your life that you don’t know anything about. We’d better get to work on figuring this stuff out” or John’s favorite, which is: “Take a guess.”

Resistance Style: The Nonverbal Provocateur
Some young clients are so good at irritating other people with their nonverbal behavior that they deserve an award. These youth are often keeping adults at a distance because they don’t trust that the adults will understand or appreciate their adolescent dilemmas. These youths also are notorious for being able to “piss off” their parents, teachers, probation officers, and therapists. They may do so through eye-rolls, sneers, lack of eye contact, or other irritating nonverbal behaviors. Analytic theorists believe this is because they have such profound self- hatred that they unconsciously believe they deserve to be treated poorly by others, especially adults (Willock, 1986, 1987).

SAMPLE STATEMENT: “Yeah, right. Duh” (while youth’s eyes roll back and she heaves a significant sigh).

Formula Responses: When faced with the nonverbal provocateur, we recommend using the strategy we have referred to elsewhere as “interpersonal interpretation” (See Tough Kids, Cool Counseling). This strategy includes several steps. First, the therapist allows the youth to make whatever disrespectful nonverbal behaviors she wants to, without acknowledgment. Second, after a substantial number of eye-rolls, etc., have occurred, the therapist makes a statement such as: “Are people treating you okay.” This statement is designed to provoke complaints from the youth about whomever has been treating her so poorly. Third, the therapist discloses his or her reactions to the nonverbal behaviors: “The reason I bring this up is because, for a moment, significant sigh).I felt like being mean to you.” Fourth, the therapist suggests that the youth may already realize why the therapist “felt like being mean” to the youth or discloses that these feeling arose in response to the youth’s nonverbal behaviors. Fifth, the therapist suggests that the reason other people are treating the youth poorly is related to eye-rolls, etc., outside of therapy. Sixth, the therapist inquires as to whether the youth has control over his/her irritating nonverbal behaviors. Seventh, the therapist encourages the youth to conduct an experiment to see how people treat him/her one day when using lots of eye-rolls and another day while not using eye-rolls.

Resistance Style: The Absent Youth
There are at least two types of absent youths. First, there are young people who arrive with their parent or parents, but who refuse to leave the waiting room. Second, there are young clients who, after an initial appointment, keep missing their subsequent appointments.
In either case, resistance is high. These youth may be even more afraid of therapy and losing power the control than other youth, who at least make it into the counseling office.

SAMPLE STATEMENT: “I’m not going back and you can’t make me.”

2011-08-26_17-47-55_466

 

Formula Responses: It’s essential that young clients or students not be “dragged” into the therapy office. Therefore, the youth is simply informed that the session(s) will proceed without the youth present but that the session will still be “about” the youth. Subsequently, the session focuses on parent education and family dynamics. During this session, therapist should offer and serve food and drink to the participating family members. Also, partway through the session (if the young client is in the waiting room) one family member may ask once more if the youth would like to join them in the meeting. However, this request should only occur once and it should not involve any pleading. For young clients who miss their appointments, an invitation letter as suggested by White and Epston may be useful or, if you’re more behaviorally inclined, a contingency program may be designed to provide the youth with appropriate reinforcers and consequences.

Resistance Style: The Attacker
Similar to Matt Damon in the film Good Will Hunting, some youth will try to provoke the therapist by attacking whatever therapist personal traits that he or she can identify. It may be office decor, personal items (e.g., family pictures), clothing, the office itself, the voice tone, body posture, attractiveness, etc. The attacker’s ploy is often clear from the outset: The best defense (aka: resistance) is a good offense.

SAMPLE STATEMENT: “I noticed that everyone else here has a bigger office than you. You have a shitty little office; you must be a shitty little therapist.”

Formula Responses: We believe that two rules are crucial with young clients who consistently verbally attack the therapist. First, unlike Robin William’s character in the popular movie, you should not attempt to “choke” the youth (even therapist’s though you may feel like choking the client). In other words, therapists should not respond defensively or offensively to attacks by the youth. Second, the therapist may interpret the youth’s behavior by clearly demonstrating that the comments, whether true or not, say much more about the youth than they say about the therapist. After a few interpretations of the youth’s underlying psychodynamics, the youth usually will cease and desist with the attacks because he or she sees that every attack comes back to him or her in the form of an interpretation.

Resistance Style: The Apathetic Youth
The apathetic youth is similar to the denier, except that the formidable strategy of simply not caring about anyone or anything is the primary defense. This defense often arises out of depressive or substance related emotional and behavioral problems

SAMPLE STATEMENT: “Trust me, I really don’t give a shit about anything you’re saying!”

Formula Responses: Hanna and Hunt (1999) recommended using a sub-personality or ego state approach to dealing with adolescent apathy. This approach involves three steps: (a) take great care to empathize with the youth’s apathy; this might involve saying things like, “Okay, okay, I get it, you really don’t give a shit.”; (b) after empathizing, use a question like, “I know you don’t care, but isn’t there a little part of you, maybe a voice in the back of your head or something, that worries, maybe only a tiny bit about what might happen to you?”; (c) focus on the part of the youth that acknowledges caring about what happens and eventually begin labeling the “caring” part of the adolescent as the “real” self, while reducing the apathetic part of the self to the “fake” self.

More information about how to work through resistance is in our Tough Kids, Cool Counseling book, which happens to have five 5-star ratings on Amazon. Check it out:
http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=asap_bc?ie=UTF8

 

 

Boys and Men, Personal Reflections, Tough Kids, Tough Kids Cool Counseling

A Short Piece on Disrespecting Teenagers

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The post below is from psychotherapy.net and so you can view it there too: http://www.psychotherapy.net/blog/title/a-short-piece-on-disrespecting-teenagers

Also, I strongly recommend that you check out psychotherapy.net as a potential go-to resource on all things psychotherapeutic. Their video and streaming collection is awesome and extensive. Go to: http://www.psychotherapy.net/

Okay. Here’s the post:

A Short Piece on Disrespecting Teenagers

We have an American cultural norm to disrespect teenagers. For example, it’s probably common knowledge that teens are:
• Naturally difficult
• Not willing to listen to good common sense from adults
• Emotionally unstable
• Impulsively acting without thinking through consequences

Wait. Most of these are good descriptors of Bill O’Reilly. Isn’t he an adult?

Seriously, most television shows, movies, and adult rhetoric tends toward dismissing and disrespecting teens. It’s not unusual for people to express sympathy to parents of teens. “It’s a hard time . . . I know . . . I hope you’re coping okay.” Just last night Stephen Colbert quipped, “Nobody likes teenagers.” Even Mark Twain had his funny and famous disrespectful quotable quote on teens. Remember:

“When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much the old man had learned in seven years.”

This is a clever way of suggesting that teens don’t recognize their parents’ wisdom. Although this is partly true, I’m guessing most teens don’t find it especially hilarious. Especially if their parents are treating them in ways that most of us would consider unwise—at least if we were treated similar ways in the workplace.

And now the neuroscientists have piled on with their fancy brain images. We have scientific evidence to prove, beyond any doubt, that the brains of teens aren’t fully developed. Those poor pathetic teens; their brains aren’t even fully wired up. How can we expect them to engage in mature and rational behavior? Maybe we should just keep them in cages to prevent them from getting themselves in trouble until their brain wiring matures.

This might be a good idea, but then how do we explain the occasionally immature and irrational behavior and thinking of adults? I mean, I know we’re supposed to be superior and all that, but I have to say that I’ve sometimes seen teens acting mature and adults acting otherwise. How could this be possible when we know—based on fancy brain images—that the adult brain is neurologically all-wired-up and the teen brain is under construction? Personally (and professionally), I think the neuroscience focus on underdeveloped “teen brains” is mostly (but not completely) a form of highly scientifically refined excrement from a male bovine designed to help adults and parents feel better about themselves.

And therein lies my point: I propose that we start treating teens with the respect that we traditionally reserve for ourselves and each other . . . because if we continue to disrespect teenagers and lower our expectations for their mature behavior . . . the more our expectations are likely to come true.

John and his sister, Peggy, acting immature even though their brains are completely wired up.

Peg and John Singing at Pat's Wedding

Counseling and Psychotherapy Theory and Practice, Therapy with Adolescents, Tough Kids Cool Counseling

Handling Termination in Counseling and Psychotherapy

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It’s that time of the year (at most colleges and universities) when those of us doing and supervising counseling and psychotherapy should be thinking about how to handle termination. Well, actually we should have been thinking about it before, but if not then, now is good.

Anyway, I just sent the following termination checklist out to my MA and Doc students here at U of MT and thought this could be helpful for others, so here it is. Keep in mind that it was written for working with youth, but can be modified to stimulate your thinking about termination with whatever population with which you work.

Termination Content Checklist

[Adapted from Sommers-Flanagan, J., and Sommers-Flanagan, R., (2007).
Tough Kids, Cool Counseling: User-Friendly Approaches with Challenging Youth.
Alexandria, VA: American Counseling Association]

The following termination content checklist may be helpful for you as you plan for counseling or plan for termination. Keep in mind that this is not a comprehensive checklist that you MUST complete at the end of counseling. Also, keep in mind that the sample statements are just samples and that you should find your own words for expressing these (or similar) things. The point is that this is a guide to help you think about termination—even though some of the details will be different for you and your client(s).

_____ 1. At the outset and throughout counseling, the counselor identifies progress toward termination (e.g., “Before our meeting today, I noticed we have 4 more sessions left,” or “You are doing so well at home, at school, and with your friends. . . let’s talk about how much longer you’ll want or need to come for counseling”).
_____ 2. The counselor reminisces about early sessions or the first time counselor and client met. For example: “I remember something you said when we first met, you said: ‘there’s no way in hell I’m gonna talk with you about anything important.’ Remember that? I have it right here in my notes. You were sure excited about coming for counseling” (said with empathic sarcasm).
_____ 3. The counselor identifies positive behavior, attitude, and/or emotional changes. This is part of the process of providing feedback regarding problem resolution and goal attainment: “I’ve noticed something about you that has changed. It used to be that you wouldn’t let adults get chummy with you. And you wouldn’t accept compliments from adults. Now, from what you and your parents tell me and from how you act in here, it’s obvious that you give adults a chance. You aren’t always automatically nasty to every adult you see. I think that’s nice.”
_____ 4. Acknowledge that the relationship is ending with counseling termination: “Next session will be our last session. I guess there’s a chance we might see each other sometime, at the mall or somewhere. If we see each other, I hope it’s okay for us to say hello. But I want you to know that I’ll wait for you to say hello first. And of course, I won’t say anything about you having been in counseling.”
_____ 5. Identify a positive personal attribute that you noticed during counseling. This should be a personal characteristic separate from goals the client may have attained: “From the beginning I’ve always enjoyed your sense of humor. You’re really creative and really funny, but you can be serious too. Thanks for letting me see both those sides. It took courage for you to seriously tell me how you really feel about your mom.”
_____ 6. If there’s unfinished business (and there always will be) provide encouragement for continued work and personal growth: “Of course, your life isn’t perfect, but I have confidence that you’ll keep working on communicating well with your sister and those other things we’ve been talking about.” You may want to explicitly describe how your client doesn’t “need” counseling, but that continued counseling or counseling in the future might be helpful: “You know some people come to counseling to work on big problems; other people come because they find counseling can be useful and help them move toward personal growth or greater awareness; and other people just like counseling. You might decide you want to continue in counseling or start up again for any of these reasons.”
_____ 7. Provide opportunities for feedback to you: “I’d like to hear from you. What did you think was most helpful about coming to counseling? What did you think was least helpful?” You can add to this any genuine statements about things you wish you’d done differently as long as it’s not based on new insights. For example, if your client got angry for you for misunderstanding something and this was processed earlier, you might say: “And of course I wish I had heard you correctly and understood you the first time around on that [issue], but I’m glad we were able to talk through it and keep working together.”
_____ 8. If it’s possible, let the client know that he or she may return for counseling in the future: “I hope you know you can come back for a meeting sometime in the future if you want or need to.”
_____ 9. Make a statement about your hope for the client’s positive future: “I’ll be thinking of you and hoping that things work out for the best. Of course, like I said in the beginning, I’m hoping you get what you want out of life, just as long as it’s legal and healthy.”
_____ 10. As needed, listen to and discuss client wishes about continuing counseling forever or client wishes about transforming their relationship with you from one of counselor–client to that of parent–child or friend: “Like you’ve known all along, counseling is kind of weird. It’s not like we’re mom and daughter or aunt and niece. And even though I like you and feel close to you, it isn’t really the same as being friends” (further discussion and processing of feelings follows).

For more information on termination with youth, go to: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_3?s=books&ie=UTF8&qid=1396895008&sr=1-3

 

 

 

Parenting, Therapy with Adolescents

Hello to the Communities in Schools of North Carolina

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Tomorrow I head to Billings to fly to Charlotte, North Carolina to speak at the annual training conference for the Communities in Schools of North Carolina (CIS-NC). CIS-NC is an awesome organization that helps prevent and reduce school drop-outs. I’m honored to be a part of their annual training. You can learn more about CIS-NC at: http://www.cisnc.org/

Attached to this post is the powerpoint presentation for the Wednesday opening session.

NC CIS Warts to Wings Final REV no cartoons

And here’s the one page summary from the opening session.

From Warts to Wings Handout

And here’s the powerpoint for the break-out session on “How to Listen so Parents will Talk”

How to Listen for CIS

And the one page summary for the break-out session.

How to Listen Handout

Counseling and Psychotherapy Theory and Practice, Therapy with Adolescents

Tough Kids, Cool Counseling: Dealing with “Resistance” – Part 1

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Working with challenging, tough, or naturally resistant youth is one of the most difficult situations a counselor or psychotherapist can face. In this excerpt from chapter 3 of “Tough Kids, Cool Counseling” (published by ACA, 2007), we begin discussing strategies for dealing with this difficult situation. Here’s a link to the Amazon page for this book: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_2?ie=UTF8&qid=1370790501&sr=1-2

Chapter 3

Resistance Busters: Quick Solutions and Longer-Term Strategies

As noted in preceding chapters, adolescents are well-known for their general distrust of adults and their striving for autonomy (Erikson, 1963; Saginak, 2003). Despite this distrust and independence-striving, in most cases, by using the strategies and techniques discussed in Chapter 2, counselors can manage resistance and initiate therapy with clients and their parents. However, upon entering a counseling situation, some young people will display extreme, provocative, or puzzling resistance behaviors that require more specialized approaches (Amatea, 1988; Richardson, 2001).

Imagine the following scenario:

You’re an intern scheduled to meet with a 15-year-old girl referred to a community clinic from a local group home. You’ve been in graduate school for about 18 months and so you’re not completely naïve, but because you’re only 23 years old yourself (and you went through a fair bit of emotional turmoil during your teen years), you’re especially excited about the opportunity to help a teenager who is obviously in a challenging life situation.

When you meet your client, Maya, in the waiting room, your enthusiasm begins to wane. Her jet-black and pink fringed hair hangs over her eyes and she reeks of cigarette smoke. When you greet her, she sneers, causing her lip-ring to flip upward. Her eyes (or at least what you can see of them) roll back as if she is disgusted at the sight of you.

Her first spoken words to you are: “This is a fucking waste of my time.”

You’re not sure what to say and so the Carl Rogers voice inside of you says gently, “It sounds like you’re not very happy to be here.”

Maya’s response is to slip into a stony silence, a silence only occasionally broken with deep dramatic sighs. Eventually, when she finally speaks again, she says, “Oh my fucking God. And you’re supposed to help me?  That’s a joke.”

Some teenagers have a special talent for destroying their counselor’s confidence. Not surprisingly, our graduate students, when facing a client like Maya for the first time, are often stunned. They complain of having a blank-mind and not knowing what to say. Other common reactions to the Maya-prototype include overwhelming feelings of inadequacy (usually accompanied by anxiety) or strong impulses to retaliate with anger.

This chapter focuses on strategies and techniques for dealing with some of the most provocative behaviors you’re likely to see in counseling situations. Our belief is that counselors should prepare, plan, and look forward to aggressive resistance from teenage clients or students. Again, we emphasize that aggressive resistance is best viewed as a coping style brought into the counseling situation and directed towards anyone in authority—in Sullivan’s terms, a parataxic distortion (Sullivan, 1953). Therefore, when working with challenging youth, keep one key fact clearly in mind: Your client’s insults, disgust, and aggressive behavior, although aimed at you, have virtually nothing to do with you. There’s no point in taking your client’s comments personally, and in fact, if you can side-step the onslaught, it will provide you with all sorts of important diagnostic and clinical information about your client’s pain and defenses.

Getting Your Buttons Pushed

Despite our great advice about not taking your client’s degrading comments personally, in the real world, we all get our buttons pushed sometimes. A graphic example of counselor over-reaction to provocative client behavior was captured in the feature film, Good Will Hunting (Van Sant, 1997).

As a fan of counseling, you may recall the scene. The main character, Will, played by Matt Damon, is an extremely intelligent but emotionally disturbed young man with mathematical genius. His would-be mentor, in an effort to help Will fulfill his potential, sends him to several different counselors, none of whom are able to help Will. Finally, Will ends up in the office of Sean McGuire, played by Robin Williams.

During his initial session with McGuire, Will is his provocative and nasty self. He eventually, either accidentally, or via great intuition, begins insulting McGuire’s deceased wife and because he is still unresolved about his wife’s premature death, McGuire gets his emotional buttons pushed. The result: the counselor grabs Will around the neck and slams him up against the wall. Of course, McGuire also decides to take on Will as a client and successfully helps Will move forward in his life.

We would like to emphasize two key points related to this excellent example of resistance and countertransference from Good Will Hunting. First, be aware of your emotional buttons, seeking the support and counseling you need to be an effective and ethical counselor. Second, no matter how provocative your young clients may act, avoid using Robin Williams’s “Choking the client” technique.  It may play well in Hollywood, but physical contact with resistant, aggressive, and/or angry clients is highly ill-advised.

If you find you’re having your emotional buttons pushed occasionally by teenage clients or students, consider yourself normal. On the other hand, if the button pushing begins to cause you to contemplate acting on destructive impulses, it’s time to get therapy for yourself, and/or support from a collegial supervision group. Many psychoanalytically-oriented writers have warned about the powerful regressive countransference impulses that young clients can ignite in their counselors (Dass-Brailsford, 2003; Horne, 2001).

Pause for Reflection: How do you usually respond when you get your buttons pushed by someone? Do you instantly feel angry? Or, are you more likely to scrutinize yourself and decide that you really are just an inadequate and worthless piece of furniture? Of course, there’s no “right” response to these questions. The best guideline is to continually work at looking at yourself and your reactions to clients so that you are consistently cultivating your self-awareness.

[End of Pause for Reflection]

To work ethically and professionally with provocative clients requires general skill, personal insight, and a particular knowledge base that includes a range of potentially constructive automatic or formula responses.

Therapy with Adolescents

Information on Suicide Interventions for Counselors

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The following information is excerpted from the soon-to-be-forthcoming 5th edition of Clinical Interviewing, published by John Wiley & Sons. This includes information that I didn’t get a chance to cover during my ACA pre-conference Learning Institute yesterday. For information on the Clinical Interviewing text, see:  http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=dp_ob_title_bk

Safety Planning

The primary thought disorder in suicide is that of a pathological narrowing of the mind’s focus, called constriction, which takes the form of seeing only two choices; either something painfully unsatisfactory or cessation of life. (Shneidman, 1984, pp. 320–321)

Helping clients develop a thoughtful and practical plan for coping with and reducing psychological pain is a central component in suicide interventions. This plan can include relaxation, mindfulness, traditional meditation practices, cognitive restructuring, social outreach, and other strategies that increase self-soothing, decrease social isolation, and decrease the sense of being a social burden (Joiner, 2005).

Instead of the traditional approach of implementing no-suicide contracts, contemporary approaches emphasize obtaining a commitment to treatment statement from the client (Rudd et al., 2006). These treatment statements or plans go by various names including, “Commitment to Intervention,” “Crisis Response Plan,” “Safety Plan,” and “Safety Planning Intervention” (Jobes et al., 2008; Stanley & Brown, 2012); they’re more comprehensive and positive in that they describe activities that clients will do to address their depressive and suicidal symptoms, rather than focusing narrowly on what the client will not do (i.e., commit suicide). These plans also include ways for clients to access emergency support after hours (such as the national suicide prevention lifeline 1(800) 273-TALK or a similar emergency crisis number; Doreen Marshall, personal communication, September 30, 2012).

As a specific safety planning example, Stanley and Brown (2005) developed a brief treatment for suicidal clients, called the Safety Planning Intervention (SPI). This intervention was developed from evidence-based cognitive therapy principles and can be used in hospital emergency rooms as well as inpatient and outpatient settings (Brown et al., 2005). The SPI includes six treatment components:

  1. Recognizing  warning  signs of an  impending suicidal crisis
  2. Employing  internal coping  strategies
  3. Utilizing social contacts as a means of distraction  from suicidal  thoughts
  4. Contacting  family   members   or friends who may help to resolve the crisis
  5. Contacting mental health  professionals or agencies
  6. Reducing the  potential use of lethal  means (Stanley & Brown, 2012, p. 257)

Stanley and Brown (2012) noted that the sixth treatment component, reducing lethal means, isn’t addressed until the other five safety plan components have been completed. Component six also may require assistance from family members or a friend, depending on the situation.

Identifying Alternatives to Suicide

Suicide is a possible alternative to life. Engaging in a debate about the acceptability of suicide or whether with clients with suicidal impulses “should” seek death by suicide can backfire. Sometimes suicidal individuals feel so disempowered that the threat or possibility to take their own life is perceived as one of their few sources of control. Consequently, our main job is to help identify methods for coping with suicidal impulses and to identify life alternatives that are more desirable than death by suicide—rather than taking away clients’ rights to consider death by suicide.

Suicidal clients often suffer from mental constriction and problem-solving deficits; they’re unable to identify options to suicide. As Shneidman (1980) suggested, clients need help to improve their mood, regain hope, take off their constricting mental blinders, and “widen” their view of life’s options.

Shneidman (1980) wrote of a situation where a pregnant suicidal teenager came to see him in a suicidal crisis. She said she had a gun in her purse. He conceded to her that suicide was an option, while pulling out paper and a pen to write down other life options. Together, they generated 8-10 alternatives to suicide. Even though Shneidman generated most of the options and she rejected them, he continued writing them down, noting they were only options. Eventually, he handed the list over to her and asked her to rank order her preferences. It was surprising to both of them that she selected death by suicide as her third preferred option. As a consequence, together they worked to implement options one and two and happily, she never needed to choose option three.

This is a practical approach that you can practice with your peers and implement with suicidal clients. Of course, there’s always the possibility that clients will decide suicide is the best choice (at which point you’ve obtained important assessment information). However, it is surprising how often suicidal clients, once they’ve experienced this intervention designed to address their mental constriction symptoms, discover other, more preferable options that involve embracing life.

Separating the Psychic Pain From the Self

Rosenberg (1999; 2000) described a helpful cognitive reframe intervention for use with suicidal clients. She wrote, “The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self” (p. 86). This technique can help suicidal clients because it provides much needed empathy for the clients’ psychic pain, while at the same time helping them see that their wish is for the pain to stop existing, not for the self to stop existing.

Similarly, Rosenberg (1999) recommended that therapists help clients reframe what’s usually meant by the phrase “feeling suicidal.” She noted that clients benefit from seeing their suicidal thoughts and impulses as a communication about their depth of feeling, rather than an “actual intent to take action” (p. 86). Once again, this approach to intervening with suicidal clients can decrease clients’ needs to act, partly because of the elegant cognitive reframe and partly because of the therapist’s empathic message.

And here’s a photo of the cover of the Tough Kids, Cool Counseling book. You can get this through ACA or on Amazon: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_3?ie=UTF8&qid=1363881381&sr=1-3

Tough Kids Image

Uncategorized

Excerpt from The Initial Psychotherapy Session with Adolescent Clients

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Adolescent clients are known for their tendency to push their psychotherapist’s emotional buttons. For example:

Therapist:     I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:          You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response).

If psychotherapists are not aware of how they are likely to react to emotionally provocative situations (such as the preceding) and prepared to respond with empathy, validation, and concession, they may not be well-suited to working with adolescent clients (Sommers-Flanagan & Richardson, 2011).

Nearly all adolescents have quick reactions to therapists and unfortunately these reactions are often negative, though some may be unrealistically positive (Bernstein, 1996). Adolescents may bristle at the thought of an intimate encounter with someone whom they see as an authority figure. Having been judged and reprimanded by adults previously, adolescents may anticipate the same relationship dynamics in psychotherapy. Therapists must be ready for this negative reaction (i.e., transference) and actively develop strategies to engage clients, lower resistance, and manage their own countertransference reactions (Sommers-Flanagan & Sommers-Flanagan, 2007).

And later in the article . . .

Based on clinical experience, we recommend opening statements or questions that are like invitations to work together. Adolescent clients may or may not reject the invitation, but because adolescent clients typically did not select their psychotherapist, offering an invitation is a reasonable opening. We recommend an invitation that emphasizes disclosure, collaboration, and interest and that initiates a process of exploring client goals. For example,

I’d like to start by telling you how I like to work with teenagers. I’m interested in helping you be successful. That’s my goal, to help you be successful in here or out in the world. My goal is to help you accomplish your goals. But there’s a limit on that. My goals are your goals just as long as your goals are legal and healthy.

The messages imbedded in that sample opening include: (a) this is what I am about; (b) I want to work with you; (c) I am interested in you and your success; (d) there are limits regarding what I will help you with. It is very possible for adolescent clients to oppose this opening in one way or another, but no matter how they respond, a message that includes disclosure, collaboration, interest, and limits is a good beginning.

And finally, photo that includes me and my professional coauthor.

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