Tag Archives: choice theory

Counseling and Psychotherapy Theory and Practice

Becoming a Reality Therapist: The Reality Therapy Lab

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Let’s say you want to practice reality therapy. Maybe more than any other approach, you’ll need to use reality therapy on yourself to become a reality therapist. Here’s what I mean.

You could consider channeling a little William Glasser, because he’s the developer of reality therapy. Then again, you might not want to channel Glasser, because, as Robert Wubbolding has written, to become a reality therapist, “You need not imitate the style of anyone else.”

The point is that you get to do the choosing . . . and a great start is to choose to use Wubbolding’s summary of the delivery system of reality therapy. Wubbolding used the letters, WDEP to summarize reality therapy, and these letters also happen to appear on Wubbolding’s car license plate. If you’re getting the feeling that Wubbolding is committed to reality therapy principles, you would be absolutely right. WDEP stands for Wants, Doing, Evaluation, and Planning. The following four questions capture WDEP:

What do you want?

What are you doing?

Is what you’re doing working? [Evaluation]

Should you make a new plan?

Before enacting reality therapy, you’ll need to adopt a positive, engaged, courteous, enthusiastic, counselor demeanor. You also need to be ready to use your excellent active listening skills. Avoiding toxic relational strategies like arguing, blaming, and criticizing is crucial. Think of yourself as a mentor or coach, and then practice the following strategies to see if they fit for you.

Begin by helping your client (or role-play partner) identify what he/she/they want. You could use any of the following questions:

If we could work on something that feels important to you, what would that be?

What do you want from our meeting today?

This is a big question, but I’m going to ask it anyway: What do you want from life?

If we have a good session and accomplish something that feels good to you, what will we have accomplished?

After you’ve gotten a sense of what your client is wants, you can move onto an inquiry about how your client is currently trying to get those wants. Questions like the following might help:

How are you currently trying to get what you want?

What have you tried?

I imagine you’ve tried various strategies for getting what you want to happen in your life. Tell me about all those things you’ve tried and how they’ve worked.

You can see from this last question, that asking about what clients are doing naturally leads to what Wubbolding considers to be the most important step in reality therapy: Evaluation. Wubbolding hypothesizes that many clients don’t get taught how to self-evaluate and/or may not have much practice at self-evaluation. He uses questions like the following to prompt client self-evaluation.

Is what you’re doing helping or hurting?

Is want you want realistic and attainable?

Does your self-talk help or hinder you in your efforts to get what you want?

Wubbolding has many additional questions about how to help clients self-evaluate in his book, Reality Therapy for the 21st Century. Check it out.

This brings us to the final question: Should you make a new plan? I think one of the most important insights that reality therapy brings to the counseling table is its emphasis on active and smart planning. Although SMART plans originated in the business world, Wubbolding has an extensive guide for how to help clients make effective plans. In my experiences doing counseling and psychotherapy, I’ve been astonished at how often clients go off in search of goals with either no plans or bad plans. For Wubbolding, client plans should be: Simple, Attainable, Measurable, Immediate, Involved, Controlled, Committed, and Continuous (Wubbolding’s acronym for planning is SAMI2C3). For more information on how to create SAMI2C3 plans, see Wubbolding’s book or the chapter in our Counseling and Psychotherapy Theories in Context and Practice textbook.

All planning that happens in counseling should be collaborative planning. Your job, as you engage in this important planning step, is to come alongside clients, brainstorm small tweaks or big changes in how clients might attain their goals, and to give them constructive feedback about whether their plan is a smart plan while providing encouragement and collaboratively evaluating the plan’s effectiveness. I have no doubt that reality therapy can be effective, partly because the first three reality therapy questions are so central to human functioning, but also because a good plan is a beautiful thing.

Note: the content of this blog is primarily adapted from the section that Robert Wubbolding wrote for our theories textbook.

Counseling and Psychotherapy Theory and Practice, Happiness

Reality Therapy: Developing Effective Plans

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With Wubbolding

Thanks to Molly Molloy, the Montana Office of Rural Health, the Montana Flex Program, and the Montana Hospital Association, I had a chance to present as part of a “Rethinking Resiliency” series this morning. One question that came up had to do with how we can make better plans to facilitate our self-improvement. The best answer I could come up with was to follow Robert Wubbolding’s guidance on effective planning, from a reality therapy perspective. All of the preceding leads me to posting a section from our Counseling and Psychotherapy Theories textbook on Reality Therapy and Planning.

Here we go:

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Wubbolding (1988, 1991, 2000, 2011 . . . and pictured above) has written extensively about how reality therapists help clients develop plans for making positive life changes. Therapists help clients make positive and constructive plans. Wubbolding (1988) uses the acronym SAMI2C3 to outline the essential ingredients of an effective plan:

S = Simple: Effective plans are simple. If a plan generated in reality therapy is too complex, the client may become confused and therefore not follow through.

A = Attainable: Effective plans are attainable or realistic. If the plan is unattainable, the client can become discouraged.

M = Measurable: Effective plans are measurable. Clients need to know if the plan is working and if they’re making progress.

I = Immediate: Effective plans can be enacted immediately, or at least very soon. If clients have to wait too long to implement a plan, motivation may be compromised.

I = Involved: Helping professionals can be involved with their client’s or student’s planning. This should be done ethically and in ways that promote client independence.

C = Controlled: The planner has exclusive control over effective plans. Avoid having clients develop plans that are contingent on someone else’s behavior.

C = Committed: Clients need to commit to their plans. If a client is only half-heartedly invested in the plan, the plan is less likely to succeed.

C = Continuous: Effective plans are continuously implemented. When the process is going well, reality therapy clients have continuous awareness of what they want and of their plan for getting what they want. This high level of awareness reminds us of mindfulness or conscious-raising therapeutic techniques.

Wubbolding (1988) also recommended that individuals learning to conduct reality therapy develop a plan for themselves. He noted that to be effective reality therapists, practitioners should obtain consultation and/or supervision from certified reality therapists (in addition, we recommend that you practice living your life using choice theory rules; see Putting it in Practice 9.3).

Putting it in Practice 9.3

Living Choice Theory: The Four Big Questions

Four questions have been developed to help students and clients live the choice theory lifestyle (Wubbolding, 1988). These questions are derived from Wubbolding’s WDEP formula. During one full week, do your best to keep these four reality therapy questions on your mind:

  1. What do you want? (Wants)
  2. What are you doing? (Doing)
  3. Is it working? (Evaluation)
  4. Should you make a new plan? (Planning)

Every day you’re operating with a personal plan. The plan may or may not be any good and it may or may not be clear. The point is this: You’re thinking and doing things aimed toward getting your basic needs met. Therefore, consistently ask yourself the four preceding questions. This will help make your plan and choices more explicit.

Wubbolding’s four questions are powerful and practical. Think about how you might apply them when doing therapy with a teenager. Now think about how you might apply them as a consultant for a local business. Whether you’re consulting with a teenager or a business leader, there are hardly any other four questions that are more relevant and practical.

In the space that follows each question, answer the four questions for yourself today.

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

After you’ve answered the questions, go back and think about what you’ve written as your answer for Question 1.

Counseling and Psychotherapy Theory and Practice

Choice Theory/Reality Therapy and Spirituality

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John and Bob Wubbolding 2017 B

Counseling and psychotherapy theories are wildly variable and surprisingly convergent. What do I mean by this? Well, despite the fact that Sigmund Freud and Francine Shapiro and Steven Hayes and Marsha Linehan have very different ideas about what helps people change for the better, there’s also a boatload of commonality.

Based on my narrow range of experience and knowledge, nowhere is there more commonality than the theoretical outposts of Adlerian theory (i.e., Individual Psychology) and Choice Theory/Reality Therapy. Both of these approaches include a broad theoretical concept related to an individual’s personal and cultural construction of how they view themselves, others, and the world (i.e., Adlerians say “Lifestyle” while Reality Therapists say “Quality World”); both perspectives view individuals as pulled forward by internal values (and not driven by Freudian conflicts); both perspectives view behavior as purposeful, and perhaps not coincidently, they also view psychopathology as purposeful.

All this theory-speak is way for me to introduce this post as a continuation of my spirituality and counseling/psychotherapy theories series. What’s especially interesting about this post (IMHO) is that I’m writing about spirituality and Reality Therapy. I mean, how can a form of therapy that explicitly emphasizes “reality,” accommodate “spirituality?” We’ll see about that . . . maybe.

Chapter 9 of Counseling and Psychotherapy Theories in Context and Practice focuses on choice theory and reality therapy. Many people may not perfectly understand the definitions of choice theory and reality therapy. As a quick refresher, here’s an excerpt from the beginning of Chapter 9, followed by the brief spirituality section.

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Reality therapy is often oversimplified and confused with confrontational therapeutic approaches. In this chapter we describe and explain the nuances and clarify the confusion.

What is Choice Theory and Reality Therapy?

Glasser developed reality therapy in the 1960s. Later, recognizing that he needed a theoretical foundation for his therapeutic approach, he began exploring cybernetics and control system theory (Powers, 1973; Wiener, 1948). Initially, Glasser used control theory to explain reality therapy. Later, he adapted the theoretical model and shifted to using choice theory (Glasser, 1998).

Choice theory is based on the idea that conscious behaviors are chosen in an effort to satisfy one of five internal basic human needs (Wubbolding & Brickel, 2017). The human mind or brain acts as a “negative input control system,” providing feedback to individuals so that they can correct behaviors and continue getting what they need and want (Wubbolding, 2012, p. 13).

Reality therapy is a present-focused, directive therapeutic approach designed to help individuals identify and satisfy their needs and wants more consistently and adaptively. As Wubbolding (2012) has written, “If choice theory is the track, reality therapy is the train that delivers the product” (p. 5).

Choice Theory, Reality Therapy, and Spirituality

In the 1989 Spring issue of the Journal of Reality Therapy, Brent Dennis, a certified reality therapist, wrote an article titled, “Faith: The fifth psychological need.” Glasser (1989) responded later that year. Glasser noted that he found the discussion interesting, but that there is “no possible way to resolve an argument about belief” (p. 29). He concluded with a statement embracing inclusiveness toward whatever anyone might place in their quality world. Consistent with this perspective, contemporary reality therapists have published book chapters on how to help interfaith and multicultural couples succeed in their partnerships and marriages (Minatrea & Duba, 2012; Olver, 2012). It’s interesting however, that Glasser described faith as residing in an individual’s quality world; he did not embrace it as a new psychological human need.

In an article on integrating reality therapy into Malaysian Islamic culture, Jusoh and Ahmad (2009) described many ways in which choice theory is consistent with Islam and can be practiced in Asian cultures. Specifically, they focused on the WDEP and SAMI2C3 systems and emphasized their compatibility with Islamic concepts. They concluded that “choice theory and reality therapy have universal attributes, and these can be interpreted in any religion or culture” (2009, p. 7). This statement seems consistent with Glasser’s (1989) inclusive statement on spirituality as a potential human need.

Overall, aside from the content briefly summarized here, little information exists on the integration of spirituality into reality therapy. However, given the growing international flavor of CT/RT, progress in this area seems inevitable.

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections

A Tasty Sample of Reality Therapy

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With WubboldingAs far as I know, reality therapists don’t typically use food or eating metaphors. My use of it here might be a leftover from my Gestalt therapy chapter revision, because Gestalt theory happily incorporates swallowing, biting, and other oral dimensions. Then again, maybe it’s just time for lunch.

Choice theory is the foundation for reality therapy. Or, as William Glasser and Robert Wubbolding (featured with me in this photo) put it, reality therapy is the train and choice theory is the track. No gustatory metaphors here either. But I’ll keep looking.

The following is a smattering of tasty revisions for the forthcoming 3rd edition of Counseling and Psychotherapy Theories in Context and Practice.

What is Choice Theory and Reality Therapy?

Glasser developed reality therapy in the 1960s. Later, recognizing that he needed a theoretical foundation for his therapeutic approach, he began exploring cybernetics and control system theory (Powers, 1973; Wiener, 1948). Initially, following Powers, Glasser used control theory to explain reality therapy. Later, he adapted the theoretical model and shifted to using choice theory (Glasser, 1998).

Choice theory is based on the idea that conscious behaviors are chosen in an effort to satisfy one of five internal basic human needs (Wubbolding & Brickel, 2017). The human mind or brain acts as a “negative input control system,” providing feedback to individuals so that we can correct out behaviors and continue getting what we need and want (Wubbolding, 2012, p. 13).

Reality therapy is a present-focused, directive therapeutic approach designed to help individuals identify and satisfy their needs and wants more consistently and adaptively. As Wubbolding (2012) has written, “If choice theory is the track, reality therapy is the train that delivers the product” (p. 5).

Reality Therapy in Action: Brief Vignettes

Similar to Adlerian therapy, reality therapy involves encouragement and intentional planning. The counselor establishes a positive working relationship and then persistently keeps the therapeutic focus on what’s within the client’s solving circle or circle of control. Maintaining a clear focus on positive actions and thoughts is what makes reality therapy an efficient and brief counseling approach.

Vignette I: Using Encouragement—Not Critical Confrontation

The following is an example of the type of confrontation often inaccurately associated with reality therapy. The counselor is confronting a teenage client on his efforts to find a job.

Counselor: Where else did you go?

Client: I tried a couple other [gas] stations, too. Nobody wants to look at me. They don’t pay too good anyway. [Screw] them!

Counselor: So you haven’t really done too much looking. Sounds like you want it served on a silver plate, Joe. Do you think looking at a couple of gas stations is really going to get you a job? (XXXX et al., 2002, p. 219)

Based on this brief exchange it appears the counselor is trying to help the client be successful in obtaining employment. Consequently, we can assume that having gainful employment (or at least making money) is a “want” (the W in WDEP) and in the client’s quality world. Although this counselor is supposedly doing reality therapy, his critical statements (“you haven’t done too much looking” and “you want it served on a silver platter”) are inconsistent with reality therapy principles. A reality therapist would use a more supportive and encouraging approach. For example:

Counselor: Where else did you go?

Client: I tried a couple other [gas] stations, too. Nobody wants to look at me. They don’t pay too good anyway. [Screw] them!

Counselor (Reality therapy response): It sounds like you really want a job and you feel very frustrated. What else could you do to help get what you want?

Notice that the reality therapist keeps the focus on what the client wants, empathizes with the frustration, and ignores the client’s desire to quit trying. This approach is encouraging because the counselor is expresses confidence in the client’s ability to act and think in ways that will move him toward his quality world.

Generally, when counselors use confrontation, the goal is to help clients engage in self-examination. The process for nearly all therapy approaches is similar—counselors help clients increase their awareness or have insights, which then leads to motivation and eventual change. Consistent with this process, Wubbolding referred to client self-evaluation as a “prelude to change” (1999, p. 196).

In working with this young man on employment issues, the following exchange uses concepts and questions adapted from Wubbolding (1999).

Counselor: Hey Joe, do you think the overall direction of your life is more of a plus or more of a minus?

Client: I don’t know. I suppose it’s kind of a neutral. I don’t have a job and I’m not really going any direction.

Counselor: That’s interesting. No direction. I guess my question about that is whether going no direction is really the direction you want . . . or whether maybe you want something else?

Client: Yeah. I’d love to have some money. Right now the economy sucks, so I don’t really see the point of looking for work.

Counselor: The odds of getting a job right now aren’t great, that’s for sure. Do you suppose the odds are better if you stay home or better if you get out and drop off a few applications?

Client: I see what you’re saying. My odds are a little better if I get out there. But I think my odds of making money are probably better if I just got out there and sold drugs, like some other guys I know are doing.

Counselor: I’m just trying to follow along and track what you want. It does sound like you want money. And you might be right about the drug selling scene, I don’t know much about that. But let’s be serious, do you think selling drugs would genuinely be good for you? I guess another way of asking that is, “Will selling drugs help or hurt you in getting what you want in the long run?” [This confrontation does what a reality therapy confrontation is supposed to do: It directly questions the usefulness of excuses.]

Client: I’m not saying I think selling drugs is a good thing to do. I’m just frustrated and sick of being broke and poor.

Counselor: Yeah. It’s very hard. But I’m your counselor and it’s my job to keep pushing you in positive directions. I’m asking you this because I think you can do better than how you’re doing. Is the way you’re thinking about this—that it’s too hard, the economy sucks, and you’re likely to fail—is that line of thinking helping you get a job or hurting your prospects?

Client: Yeah. I guess having a pity-party isn’t helping much.

Counselor: I’m sure having a pity party can feel good sometimes. But I’m with you on the fact that it’s not helping much. So we’ve got to try out something different.

Because the preceding questions ask the client to look at himself and self-evaluate, they’re inherently confrontational, but also supportive and encouraging. Many additional reality therapy questions that help clients self-reflect and plan are in Wubbolding’s (2000, 2017) publications.

Vignette II: Collaborative Planning

This vignette extends the previous case into the reality therapy collaborative planning process.

Client: Well. What sort of different approach do you suggest?

Counselor: If it were up to me, I’d suggest we make a very clear plan for you to try out this week. The plan would focus on how you can get what you want: a job so you can start earning money. And we’d develop this plan together and we’d be honest with each other about whether our ideas would give you the best chances to get a job.

Client: How about I go down to the Job Service and sign up there?

Counselor: That’s one good idea. It doesn’t guarantee you a job, but nothing will because you don’t have control over whether someone hires you, you only have control over your strategy or plan. Do you know what I mean?

Client: Not really.

Counselor: Thanks for being honest about that. When you make a plan or set a goal, it’s important for it to be completely within your control and not dependent on anyone else. That’s because the only behavior you can control is your own. For example, if your plan is to “get hired,” you can be doomed to frustration and anger because you don’t make the hiring decision. Instead, a good plan involves developing a detailed, step-by-step process. Your plan could be to revise your resume and then submit it along with a well-crafted cover letter to 10 places where you think your skills are a good fit. You have complete control over all that.

Client: Okay. I get it. I could do that, but I’m not very good with writing and resumes and all that.

Counselor: How can you make sure those things are in good shape then?

Client: I could get my sister to look it over.

Counselor: When could you do that?

Client: Next week, I suppose.

Counselor: What would make it possible to do that sooner, like this week?

Client: You know, you’re really kind of pushy.

Counselor: Do you think you’d do better with someone who lets you put things off until next week? Would that be more helpful in getting you a job sooner?

Client: Right. Right. Okay. I call my sister tonight and ask if she can help me as soon as she’s available.

Counselor: That’s sounds like a great start. What time will you call her tonight?

Client: Seven o’clock. I know. Why not six? Well I figure she’ll be done with dinner by seven, that’s why.

Counselor: Good planning. Maybe I don’t have to be so pushy after all.

The preceding dialogue illustrates how counselors can use gentle and persistent questioning to lead clients toward planning that’s consistent with Wubbolding’s principles (i.e., SAMI2C3). It also illustrates how reality therapists function as collaborators to help clients or students plan for success.

Concluding Comments

The mission of the William Glasser Institute is to teach all people Choice Theory® and to use it as the basis for training in reality therapy, lead management, and Glasser Quality School education (http://www.wglasser.com/). The institute has existed for more than 44 years and there are now approximately 8,000 certified reality therapists worldwide and over 86,000 who have obtained substantial advanced reality therapy training.

William Glasser passed away in 2013. Although his advocacy for conscious, noncoercive human choice is missed, there are many other contributors to the national and international dissemination of choice theory and reality therapy. As examples, Robert Wubbolding is the director of the Center for Reality Therapy. Thomas Parish is the editor of the International Journal of Choice Theory and Reality Therapy. Patricia Robey, Nancy Buck, Jim Roy, and John Brickell are prolific contributors to the CT/RT literature (Buck, 2013; Parrish, 2017; Robey, 2017; Roy, 2014, 2017; Wubbolding & Brickell, 2017).

In Dr. Glasser’s eulogy, Wubbolding shared the following anecdote:

Quite recently, a woman approached him at his home and begged him for advice for how to deal with her 3 year-old son. He paused for a long time and then reached deep down inside his soul and gave her 2 suggestions: “Always treat him as if he is good.” And “Set up circumstances where he can only succeed.” These wise words could serve as his suggestions for all counselors. They represent for us a worldview, an attitude toward clients and his perception of all human beings. These two sentiments transcend a particular counseling system in that they summarize his legacy (September 10, 2013; http://www.realitytherapywub.com/index.php/easyblog/entry/dr-william-glasser).  

In support of Glasser’s legacy, we end this chapter with a quotation that reflects his idealism and ambition:

It is my vision to teach choice theory to the world.

I invite you to join me in this effort.

—William Glasser, Unhappy Teenagers (2002, p. 190)

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Uncategorized

The Sweet Spot of Self-Control

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The Sweet Spot of Self Control (and Anger Management)

The speedometer reads 82 miles per hour. The numbers 8 and 2, represent, to me, a reasonable speed on I-90 in the middle of Montana. Our new (and unnecessary) speed limit signs read eight-zero. So technically, I’m breaking the law by two miles per hour. But the nearest car is a quarter mile away. The road is straight. Having ingested an optimal dose of caffeine, my attention is focused.

Slowly, a car creeps up from behind. He has his cruise control set at 83 mph. He lingers beside me and edges ahead. Then, with only three car lengths between us, he puts on his blinker and pulls in front of me. Now, with no other cars in sight, there’s just me and Mr. 83 mph on I-90, three car lengths apart.

An emotion rises into awareness. It’s almost anger. But nope, it’s not anger, it’s anger’s close cousin, annoyance. I feel it in my psyche and immediately know it can go in one of three directions: It could sit there and remain itself, until I tire of it; if I feed it, it could rise up and blossom into full-blown anger; or, I can send it away, leaving room for other thoughts and actions.

This is fabulous. This is the Sweet Spot of Self-Control.

Anger is lurking there, I know. I see it peeking over the shoulder of its cousin. “Hello anger,” I say.

In this sweet spot, I experience expanding awareness, a pinch of energy, along with an unfolding of possibilities. I love this place. I love the feelings of strength and power. I also recognize anger’s best buddy, the behavioral impulse. This particular impulse (they vary of course), is itching for me to reset my cruise control to 84 mph.  It’s coming to me in the shape of a desire—a desire to send the driver in front of me a clear message.

“You should cut him off,” the impulse says, “and let him know he should get a clue and give you some space.”

The sweet spot is sweet because it includes the empowered choice to say “No thanks” to the impulse and “See you later” to anger.

Now I’m listening to a different voice in my head. It’s smaller, softer, steadier. “It doesn’t matter” the voice whispers. “Let him creep ahead. Revenge only satisfies briefly.”

I feel a smile on my face as I remember an anger management workshop. With confidence, I had said to the young men in attendance, “No other emotion shifts as quickly as anger. You can go from feeling completely justified and vindicated, but as soon as you act, you can feel overwhelmed with shame and regret.”

A man raised his hand, “Lust” he said. “Lust is just like anger. One second you want it more than anything, but the next second you wish you hadn’t.”

“Maybe so,” I said. “Maybe so.”

There are many rational reasons why acting on aggressive behavioral impulses is ill-advised. Maybe the biggest is that the man in the car wouldn’t understand my effort to communicate with him. This gap of understanding is common across many efforts to communicate. But it’s especially linked to retaliatory or revenge-filled impulses. When angry, I can’t provide nuance in my communication and make it constructive.

The quiet voice in my brain murmurs: “You’re no victim to your impulses. You drive the car; the car doesn’t drive you.” That doesn’t make much sense. Sometimes the voice in my head speaks in analogy and metaphor. It’s a common problem. I want straight talk, but instead I get some silly metaphor from my elitist and intellectual conscience.

But I do get it and here’s what I get. I get that my conscience is telling me that this sweet spot is sweet because I get to see and feel my self-control. Not only do I get to see my behavioral options, I get to see into the future and evaluate their likely outcomes. I get to reject poor choices and avoid negative outcomes linked to aggressive actions. I’m not a victim of annoyance, anger, or aggressive impulses. I get to make the plan. I get to drive the car.

Now that other driver is far ahead.

Being on a Montana freeway, it’s hard to not think of deer. It’s clear now, but at dusk, deer will be everywhere. They have an odd instinct. Freud and my elitist conscience are inclined to call it a death instinct. Here’s how it works:

When I drive up alongside a deer on the side of the road, it dashes ahead, running alongside me; then it tries to cut across in front of me. This is the coup de gras of bad judgment. I’m in a big metal machine. The deer isn’t. So the deer dies. Not a good choice for the deer.

Yesterday, my phone alerted me to a Youtube speech by an unnamed alt right big-man. I watched and listened. So much smugness I was sick. In the end he shouted out “Hail Trump” and a few others jumped up and gave the “Heil Hitler!” salute.

Like a crazed deer, I felt an instinct. I wanted to drive to D.C. or Whitefish, Montana and find unnamed alt-right man and cut him off with some uncivil discourse. Instead, because I have a frontal lobe, I walked to the gym. Upon arriving, I discovered I’d stepped in dog poop. I’m sure this was an annoying but meaningful metaphor for something. At least that’s what my metaphor-loving conscience suggested. I didn’t buy it. Instead, I muttered “WTF” to myself. Okay, so maybe I muttered “WTF” several times. Then I walked outside in my socks and started cleaning the poop off my shoe. Not an easy task, especially if you’re wearing brand new trail-runners. I had to find a restroom near my office, an old toothbrush, lots of foamy soap, and mindfully scrub away the poop.

I was reminded of something my daughter Rylee once said at age three. She was being carried down a hill and there were many small piles of deer scat. She noticed, commenting: “I didn’t know the poop was so deep.”

Neither did I.

But the good news is that I (like you) own a functional frontal lobe that gifts me with the Sweet Spot of Self-Control. Many of us will be mindfully removing the metaphorical shit from our shoes for some time into the future. So let’s make some plans. Not revenge-laced plans; they don’t last. Yes. Let’s pause in the special sweet spot, evaluate our alternatives, and make some excellent plans.

rita-and-john-tippet

Clinical Interviewing, Suicide Assessment and Intervention

R-I-P-SC-I-P: An Acronym for Remembering the Essential Components of a Suicide Assessment Interview

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This post is part 1 of a follow up to requests I’ve gotten following the MUS Suicide Prevention Summit in Bozeman. A number of people asked: What’s R-I-P-SC-I-P and how do I get more information about it? The answer is that it’s just an acronym to help practitioners recall key areas to cover in a comprehensive suicide assessment interview. But because I made it up in honor of Robert Wubbolding while doing a workshop in Cincinnati (he’s created several acronyms for Choice Theory and Reality Therapy), I’m pretty much the only source.

The following is a pre-published excerpt from the Suicide Assessment chapter in the forthcoming 6th edition of Clinical Interviewing. It includes some general information, a summary of R-I-P-SC-I-P, and some guidance on how to talk with clients about suicide ideation. Much more of this is in the whole chapter, but I can’t post it here.

Suicide Assessment Interviewing

A comprehensive and collaborative suicide assessment interview is the professional gold standard for assessing suicide risk. Suicide assessment scales and instruments can be a valuable supplement—but not a substitute—for suicide assessment interviewing (see Putting It in Practice 10.1).

A comprehensive suicide assessment interview includes the following components:

  • Gathering information about suicide risk and protective factors: This should be done in a manner that emphasizes your desire to understand the client and not as a checklist to estimate risk
  • Asking directly about possible suicidal thoughts
  • Asking directly about possible suicide plans
  • Gathering information about client self-control and agitation
  • Gathering information about client suicide intent and reasons to live
  • Consultation with one or more professionals
  • Implementation of one or more suicide interventions, including, at the very least, collaborative work on developing an individualized safety plan
  • Detailed documentation of your assessment and decision-making process (Table 10.3 includes an acronym to help you recall the components of a comprehensive suicide assessment interview)

Table 10.3: RIP SCIP – A Suicide Assessment Acronym

R = Risk and Protective Factors
I = Suicide Ideation
P = Suicide Plan
SC = Client Self-Control and Agitation
I = Suicide Intent and Reasons for Living
P = Safety Planning

These assessment domains or dimensions form the acronym R-I-P-SC-I-P (pronounced RIP SKIP).

Exploring Suicide Ideation

Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.

Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can seem rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.

The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.

Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:

  • Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
  • I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
  • I want my clients to share their suicidal thoughts.
  • If my clients share their suicidal thoughts and plans, I can handle it!

If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.

Asking Directly about Suicide Ideation

Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.

Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.

A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:

Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)

A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.

Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask: “When was the last time when you had thoughts about suicide?” Gentle assumption can make it easier for clients to disclose suicide ideation.

Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.

1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)

2. Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)

3. What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)

4. What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)

5. What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)

6. For you, what would be a normal mood rating on a normal day? (Clients define their normal.)

7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)

8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.

Responding to Suicide Ideation

Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?

First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:

Given the stress you’re experiencing, it’s not unusual that you think about suicide sometimes. It sounds like things have been really hard lately.

This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.

As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.

  • Frequency: How often do you find yourself thinking about suicide?
  • Triggers: What seems to trigger your suicidal thoughts? What gets them started?
  • Duration: How long do these thoughts stay with you once they start?
  • Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?

As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.

Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.

Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.

On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.

Parenting, Therapy with Adolescents

The Seven Magic Words for Parents

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Children become adults by practicing. Some of this practicing involves having the right to make choices, even bad and painful choices. For parents who have not learned to back down, we offer the seven magic words. These are words derived from our study of choice theory (Glasser, 1998, 2002). The good news is that by using these words parents can share their thoughts, feelings, and wishes with their children in way that might help a rebellious child hear their viewpoint. The bad news is that after carefully expressing themselves, parents then acknowledge that ultimately, compliance is not mandatory. And there’s even more bad news:  These words aren’t really magic and parents will need more than seven of them to make them work at all.

The seven magic words are a frame for direct, powerful, and noncontrolling communication. They are: “I want you. . . but it’s your choice.” These framing words allow parents to express whatever they want (we encourage positive words) while at the same time acknowledging their child’s power and right to self-determination. By explicitly acknowledging their children’s right to self-determination, parents may reduce their children’s need to prove their independence. Examples of the seven magic words in action include:

  • I want you to stay clean and sober at the party tonight because I love you, and I know if you get caught, you might end up kicked off the basketball team, and also, your dad and I can’t trust you with the car if we know you drink, but of course I know I can’t control you, so it’s your choice.
  • I want you to graduate from high school, go to college, have a great job, and get rich, but whether or not that happens is really up to you.
  • You know I want you to be healthy, eat well, and exercise, but whether you do that is your business. I’ll help you any way I can, but it’s your choice.

As you can see, the magic words are a frame for parents to express their own beliefs and convictions. This technique allows parents to directly express heartfelt feelings, and even describe the consequences they fear, but to then turn the choice back over to the child.

Some parents will be disappointed with the seven magic words. They wish for true magic and true control. Instead, this frame merely offers an opportunity to briefly and succinctly communicate personal and family values directly to children. In many families, one of these values is to acknowledge and honor the children’s individual freedom and ultimate rights to choose how to live their lives.  Most parents want their children to learn how to make responsible, life-enhancing choices.

Go to http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118012968.html to purchase a copy of “How to Listen so Parents will Talk and Talk so Parents will Listen as an excellent, but belated, holiday gift for someone you love:).

Parenting, Therapy with Adolescents

Give Information and then Back-Off: A Choice Theory Parenting Assignment

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Parent Homework Assignment 8-1 — From How to Listen so Parents will Talk . . . http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=sr_1_8?s=books&ie=UTF8&qid=1341892854&sr=1-8&keywords=how+to+listen+so+parents+will+talk+and+talk+so+parents+will+listen

Choice Theory Communication Skills Training: How to Provide Information and Then Back Off, Instead of Trying Too Hard to Control Your Child’s Decision Making

As a loving parent, if you’re concerned about your children’s behaviors, you’ll probably have a strong and nearly irresistible impulse to tell them how to live their lives. After all, you’re the adult and they should listen to your excellent advice. You may feel the urge to say:

  • You need to clean your room now because being disorganized and undisciplined is a bad habit that will make your life miserable.
  • Alcohol and drugs are illegal and so if you go out and behave illegally, I’ll call the police and have you ticketed.
  • You need to start caring about your grades at school and that means scheduling time for homework and studying for tests.
  • Swearing is unacceptable in this house and if you do it again, I’ll wash your mouth out with soap.

Unfortunately, as you may recall from your own childhood, when parents are bossy and insistent about how things should be, children often become more stubborn and resistant. Then parents begin to nag and lecture and the pattern of advice-giving and advice-rejection deepens. This assignment is designed to help you communicate important information to your children without starting an all-out power struggle or negative nagging pattern. The following suggestions are appropriate only if the situation isn’t dangerous and you don’t need to jump in and directly and forcefully protect your children:

1. Ask permission. If you have a strong opinion that you’d like your child to hear, try asking permission to share it. Say something like, “Can I share my opinion on this with you?” Then, either your child will say “yes” and you can share your opinion or she’ll say “no” and then you’ll need to accept her boundary (in response to a “no,” you might say, “Okay. Thanks for being honest with me. Let me know if you change your mind” and then walk away).

2. Express your intention not to express your opinion. You could try telling your child, “I have an opinion on this, but I trust that you can work it out, or that you’ll ask me for help if you need it. So I’m going to try to keep my mouth shut for now.” This gives your child the message that you’re trying to respect his ability to work out his own problems. You can also add humor into this or other power-sharing techniques by adding: “You should really appreciate this, because you know how hard it is for me to keep my mouth shut and not give you advice.”

3. Provide your information or opinion and then back off.  If you can’t resist giving your opinion, just do it and then back off and let your child consider your input. The key to this strategy is patience. Undoubtedly, you’ll provide excellent advice and then your child will look like she’s not considering your advice and so you’ll have the urge to repeat your advice over and over until you see action. Instead of falling into this pattern, try saying, “Look. I’ve got an opinion, which you probably already know. But instead of staying quiet, I’m just going to say it and then let you make your own decision on how to handle your situation. It’s your life. You have to make your own decisions. But I love you and can’t stop myself from telling you what I think, so here it is.”

As you probably already know, if you express your opinion you may get a strong emotional response (e.g., “I’m fifteen years old and I can make my own decisions!”). Although this seems weird, if you give lots of advice, your children may see your ideas and opinions as evidence that you don’t believe they’re competent to make their own decisions. This is why you should always express your advice with love and concern; avoid sounding as if your main goal is to control your child’s behavior.

Finally, if the situation is dangerous or potentially so, skip the less direct parenting recommendations listed above and instead think strategically about how to deliver direct advice that will be heeded. You’ll probably need to use a more direct approach than is described here, and you may need to consult with a professional.

More assignments like this and more are in the book, How to Listen so Parents will Talk — http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=sr_1_8?s=books&ie=UTF8&qid=1341892854&sr=1-8&keywords=how+to+listen+so+parents+will+talk+and+talk+so+parents+will+listen

Counseling and Psychotherapy Theory and Practice

Reflections on Another Counselng and Psychotherapy Video Shoot

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

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

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

1. What do you want?

2. What are you doing?

3. Is it working?

4. Should you make a new plan?

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

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

What am I doing? — Typing up this blog

Is it working? — Nope!

Should I make a new plan? — Good night!