Tag Archives: Counseling

Clinical Interviewing, Suicide Assessment and Intervention

Our Upcoming ACA Book on Suicide Assessment and Treatment Planning: Sneak Peek #2

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River Rising 2020

Hey,

I hope you’re all okay and social distancing and mask wearing and hand-washing and staying healthy and well.

Today I’m working on Chapter 6 – The Cognitive Dimension in Suicide Assessment and Treatment Planning (or something like that).

As always, please share your feedback. Or, if you have no feedback and like what you read, just share the post, because, as we all know, acts of kindness grow happiness.

Here’s an excerpt on working with hopelessness.

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Working with Hopelessness as it Emerges During Sessions

Clinicians can address hopelessness in two ways. First, when hopelessness emerges in the here-and-now, clinicians need to be ready to respond empathically and effectively. Client hopelessness manifests in different ways. Sometimes hopelessness statements have depressing content (e.g., “I’ve never been happy and I’ll never be happy”); other times hopelessness statements include irritability (e.g., “Counseling has never worked for me. I hate this charade. It won’t help.”). Either way, in-session hopelessness statements can be provocative and can trigger unhelpful responses from counselors. Preparing yourself to respond therapeutically is important.

Second, hopelessness among clients who are depressed and suicidal manifests as an ongoing, long-term cognitive style. As with most cognitive styles, hopelessness is linked to cognitive distortions wherein clients have difficulty (a) recalling past successes, (b) noticing signs of hope in the immediate moment, or (c) believing that their emotional state or life situation could ever improve. We address in-session hopelessness next and hopelessness as a longer-term cognitive distortion in the subsequent section.

Expressing Empathy

Imagine you’re working with a new client. You want to be encouraging, and so you make a statement about the potential for counseling to be helpful. Consider the following exchange:

Counselor: After getting to know you a bit, and hearing what’s been happening in your life, I want to share with you that I think counseling can help.

Client: I know you mean well, but this is a waste of time. My life sucks and I want to end it. Popping in to chat with you once a week won’t change that.

When clients make hopelessness statements, you may feel tempted to counter with a rational rebuttal. After all, if client hopelessness represents a pervasive depression-related cognitive distortion or impairment, then it makes sense to offer a contrasting rational and accurate way of thinking. Although instant rational rebuttals worked for Albert Ellis, for most counselors, immediately disputing your clients’ global, internal, and hopeless cognitions will create resistance. Instead, you should return to an empathic response.

Counselor: I hear you saying that, right now, you don’t think counseling can help. You feel completely hopeless, like your life sucks and is never going to change and you just want it to end.

Staying empathic—even though you know that later you’ll be targeting your client’s hopeless distorted thinking—requires accurately reflecting your clients’ hopelessness. You may even use a tiny bit of motivational interviewing amplification (i.e., using the phrase, “never going to change” could function as an amplification). What’s important to remember about this strategy is that mirroring your clients’ hopelessness will likely stand in stark contrast to what your clients have been experiencing in their lives. In most situations, if your clients have spoken about their depression and suicidality with friends or family, they will have heard responses that include reassurance or emotional minimization (e.g., “I’m sure things will get better” or “You’re a wonderful person, you shouldn’t think about suicide” or “Let’s talk about all the blessings you have in your life”).

Remaining steadily empathic with clients as they express hopelessness is an intentionally different and courageous way to do counseling. Staying empathic means that you’re sticking with your clients in their despair. You’re not running from it; you’re not minimizing it; you’re not brushing it aside as insignificant. Instead, you’re resonating with your clients’ terribly depressive and suicidal cognitive and emotional experiences.

If you choose the courageous and empathic approach to counseling, you need to do so with the conscious intention of coming alongside your clients in their misery. Following the empathic path can take you deep into depressive ways of thinking and emoting. This can affect you personally; you may begin adopting your clients’ impaired depressive thinking and then feel depressed yourself. Part of being conscious and intentional means you’re choosing to temporarily step alongside and into your clients’ depressive mindset. You need to be clear with yourself: “I’m stepping into the pit of depression with my client, but even as I’m doing this, my intention is to initiate Socratic questioning or cognitive restructuring or collaborative problem-solving when the time is right.”

The next question is: “How long do you need to stay alongside your client in the depressive mindset?” The answer varies. Sometimes, just as soon as you step alongside your clients’ hopelessness, they will rally and say something like, “It’s not like I’m completely hopeless” or “Sometimes I feel a little hope here or there.” When your client makes a small, positive statement, your next job is to gently nurture the statement with a reflection (e.g., “I hear you saying that once in a while, a bit of hope comes into your mind”), and then explore (and possibly grow) the positive statement with a solution-focused question designed to facilitate elaboration of the exceptional thought (e.g., “What was different about a time when you were feeling hopeful?”). Then, for as long as you can manage, you should follow Murphy’s (2015) solution-focused model for working with client exceptions. This includes:

  1. Elicit exceptions. (You can do this be asking questions like “What was different. . .” and by using the motivational interviewing techniques of coming alongside or amplified reflection.)
  2. Elaborate exceptions. (You do this with questions like “What’s usually happening when you feel a bit of hope peek through the dark clouds?”)
  3. Expand exceptions. (You move exceptions to new contexts and try to increase frequency, “What might help you feel hope just a tiny bit more?”)
  4. Evaluate exceptions. (You do this by collaboratively monitoring the utility or positivity of the exception, “If you were able to create reminders for being hopeful to use throughout the day, would you find that a plus or minus in your life?”)
  5. Empowering exceptions. (You do this by giving clients credit for their exceptions and asking them what they did to make the exceptions happen, “How did you manage to get yourself to think a few positive thoughts when you were in that conflict with your supervisor?”).

In other cases, you’ll need to stick with your clients’ misery and hopelessness longer. However, because this is a strength-based model and because the evidence suggests that clients who are suicidal sometimes need their counselor to explicitly lead them toward positive solutions, you will need to watch for opportunities to turn or nudge or push your clients away from abject hopelessness.

 

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention, Therapy with Adolescents, Writing

A Sneak Peek at Our Upcoming Suicide Assessment and Treatment Book with the American Counseling Association

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Spring Sunrise and Hay

Rita and I are spending chunks of our social distancing time writing. In particular, we’ve signed a contract to write a professional book with American Counseling Association Publications on suicide assessment and treatment planning. We’ll be weaving a wellness and strength-oriented focus into strategies for assessing and treating suicidality.

Today, I’m working on Chapter 6, titled: The Cognitive Dimension. We open the chapter with a nice Aaron Beck quotation, and then discuss key cognitive issues to address with clients who are suicidal. These issues include: (a) hopelessness, (b) problem-solving impairments, (c) maladaptive thinking, and (d) negative core beliefs.

Then we shift to specific interventions that can be used to address the preceding cognitive issues. In the following excerpt, we focus on collaborative problem solving and illustrate the collaborative problem-solving process using a case example. As always, feel free to offer feedback on this draft content.

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Collaborative Problem-Solving

Though not a suicide-specific intervention, problem-solving therapy is an evidence-based approach to counseling and psychotherapy (Nezu, Nezu, & D’Zurilla, 2013). Components of problem-solving are useful for assessing and intervening with clients who are suicidal. As Reinecke (2006) noted, “From a problem-solving perspective, suicide reflects a breakdown in adaptive, rational problem solving. The suicidal individual is not able to generate, evaluate, and implement effective solutions and anticipates that his or her attempts will prove fruitless” (p. 240).

Extended Case Example: Sophia – Problem-Solving

In Chapter 5 we emphasized that clinicians should initially focus on and show empathy for clients’ excruciating distress and suicidal thoughts. However, there often comes a moment when a pivot toward the positive can occur. Questions that help with this pivot include:

  • What helps, even a tiny bit?
  • When you’ve felt bad in the past, what helped the most?
  • How have you been able to cope with your suicidal thoughts?

In response to these questions, clients who are suicidal often display symptoms of hopelessness, mental constriction, problems with information processing, or selective memory retrieval. Statements like, “I’ve tried everything,” “Nothing helps,” and “I can’t remember ever feeling good,” represent cognitive impairments. Even though your clients may think they’ve tried everything, the truth is that no one could possibly try everything. Similarly, although it’s possible that “nothing” your client does helps very much, it’s doubtful that all their efforts to feel better have been equally ineffective. These statements indicate black-white or polarized thinking, as well as hopelessness and memory impairments (Beck et al., 1979; Reinecke, 2006; Sommers-Flanagan & Sommers-Flanagan, 2018).

Pivoting to the Positive

Picking up from where we left off in Chapter 5, after exploring the distress linked to Sophia’s suicide ideation in the emotional dimension, the counselor (John) pivots to asking about the positive (“What helps?”) and then proceeds into a problem-solving assessment and intervention strategy. One clearly identified trigger for Sophia’s suicidal thinking is her parent’s fighting. She cannot directly do anything about their fights, but she can potentially do other things to shield herself from the downward cognitive and emotional spiral that parental fighting activates in her.

John: Let’s say your parents are fighting and you’re feeling suicidal. You’re in your room by yourself. What could you do that’s helpful in that moment? [The intent is to shift Sophia into active problem-solving.]

Sophia: I have a cat. His name is Douglas. Sometimes he makes me feel better. He’s diabetic, so I don’t think he’ll live much longer, but he’s comforting right now.

John: Nice. My memory’s not perfect, so is it okay with you if I write a list of all the things that help a little bit? Douglas helps you be in a better mood. What else is helpful?

Sophia: I like music. Blasting music makes me feel better. And I play the guitar, so sometimes that helps. And volleyball is a comfort, but I can’t play volleyball in my room.

John: Yeah. Great. Let me jot those down: music, guitar, volleyball, and being with your cat. And volleyball, but not in your room! I guess you can think about volleyball, right? And how about friends? Do you have friends who are positive supports in your life?

Although the fact that Douglas the cat has diabetes includes a depressive tone, the good news is that Sophia immediately engages in problem-solving. She’s able to identify Douglas and other things that help her feel better.

Throughout problem-solving, regularly repeating positive coping strategies back to the client is important. In this case, John summarizes Sophia’s positive ideas, and then asks about friends and social support—a very important dimension in overall suicide safety planning.

Sophia: Yeah, but we’re all busy. My friend Liz and I hang out quite a bit. I can walk into her house, and it will feel like my house. But we’re both in volleyball, so we’re both really busy. But our season will end soon. Hopefully that will help.

John: Ok, the list of things that seem to help, especially when you’re in a hard place with your parents fighting: Douglas the cat, music, guitar, and volleyball, and friends. Anything else to add?

Sophia:  I don’t think so.

Often, the next step in collaborative problem-solving is to ask clients for permission to add to the list, thus turning the process into a shared brain-storming session. At no time during the brainstorming should you criticize any client-generated alternatives, even if they’re dangerous or destructive. In contrast, clients will sometimes criticize your ideas. When clients criticize, just agree with a statement like, “Yeah, you’re probably right, but we’re just brainstorming. We can rank and rate these as good or bad ideas later.”

Overall, the goal is to use brainstorming to assess for and intervene with mental constriction. During brainstorming, Sophia and John generated 13 things Sophia could do to make herself feel better. Sophia’s ability to brainstorm in session is a positive indicator of her responsiveness to treatment.

 

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

Free Video Links for Online Teaching

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JSF Travel

This past week I’ve been grateful for the many professionals and organizations (including my publisher, John Wiley & Sons) who are providing free guidance and materials to help with the transition from face-to-face teaching to online instruction. In an effort to contribute back in a small way, I’m posting 10 counseling- and psychotherapy-related videos that can be integrated into online teaching. These videos are free and posted on my YouTube channel. The links are all below with a brief description of the video content.

Some of these videos are rough cuts and all of them are far from perfect demonstrations; that’s partly the point. Although many of the videos show reasonably good counseling skills and interesting assessment processes and therapeutic interventions, none of the videos are scripted, and so there’s plenty of room for review, analysis, critique, and discussion. You can show them as efforts to do CBT, SFBT, Motivational Interviewing, administration of a mental status examination, etc., and prompt students to describe how they would do these sessions even better.

These videos are meant to stimulate learning. In an ideal world, I would include a list of discussion questions, but I’ll leave that to you. If you like, please feel free to use these videos for educational purposes. Here’s the annotated list with video links:

  1. Counseling demonstrations with a 12-year-old.
    1. Opening a counseling session: https://www.youtube.com/watch?v=rHHrMC8t6vY
    2. The three-step emotional change trick: https://www.youtube.com/watch?v=ITWhMYANC5c
    3. John SF demonstrates the What’s Good About You? informal assessment technique: https://www.youtube.com/watch?v=MUhmLQUg_g8
    4. Closing a session: https://www.youtube.com/watch?v=GpuH80tf2jM
  2. Demo of assessment for anger management with a solution-focused spin with a 20-year-old client: https://www.youtube.com/watch?v=noE2wMMNLY4
  3. Demo of motivational interviewing with a 30-year-old client: https://www.youtube.com/watch?v=rtN7kEk0Sv4
  4. Demo of the affect bridge technique with an 18-year-old: https://www.youtube.com/watch?v=fEtiGuc914E
  5. Demo of CBT for social anxiety with a graduate student: https://www.youtube.com/watch?v=jfVeeGJHFjA
  6. Demo of an MSE with a 20-year-old: https://www.youtube.com/watch?v=adwOxj1o7po
  7. A lecture vignette of a demonstration of psychoanalytic ego defense mechanisms: https://studio.youtube.com/video/E818UlgHMXY/edit
  8. The University of Montana Department of Counseling does a spoof video of The Office: https://www.youtube.com/watch?v=eM8-I8_1CqQ

Good luck with the transition to online teaching and stay healthy!

John S-F

Counseling and Psychotherapy Theory and Practice, Happiness, Personal Reflections, Writing

Happiness Homework: Week 2 — University of Montana

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Peg and John Singing at Pat's Wedding

Yesterday the happiness class focused on the context of happiness and happiness habits. On my powerpoint slides, I managed to reverse the numerator and denominator of Bono’s happiness equation, resulting in my abject humiliation in front of the class. This led to my personally disclosing my most humiliating experience ever, thereby demonstrating how contextual experiences in the here-and-now can trigger memories that can then either magnify or minimize an experience of happiness or unhappiness in the moment. I’ll spare you the details of my historical humiliations, and instead, direct you toward this week’s happiness homework assignments.

By now, students have read chapters one and two in Tim Bono’s book, “When Likes Aren’t Enough: A crash course in the science of happiness.” Additionally, they listened to a Hidden Brain podcast on Creatures of Habit: https://www.npr.org/transcripts/787160734, and watched a short Forest Bathing video: https://www.youtube.com/watch?v=W0MEFNyLPag

The two take-home assignments of the week are described below:

Active Learning Assignment 3 – Three Happy Places

More often than we might think, our environment, setting, or context directly influences our mood and sense of well-being. This is most obvious when we’re in settings or environments that we find aversive.

To start this assignment, reflect briefly on environments, settings, or contexts that you find aversive. For example, some people find cloudy days, rain, smoky skies (or rooms), or particular temperatures aversive or uncomfortable. Other people might find churches, gyms, or libraries aversive.

Now, consider the opposite: What environments, settings, or contexts do you find pleasurable, comforting, or energizing? As you may have noticed in the short “Forest bathing” video, there’s evidence that, in general, more time in the outdoors is linked to increased feelings of well-being. For this assignment, don’t worry about what “should” be your happy place. . . but if the outdoors is a happy place for you, be sure to include it.

After reading and reflecting on the above, write a few words (short answers) in response to the following prompts:

  1. List three settings that usually trigger negativity or discomfort in you.
  2. List three settings that usually trigger happiness and wellbeing in you (and be specific). These are your happy places
  3. What can you do to prepare for or cope with challenging settings that usually cause you discomfort? (Other than avoiding them)
  4. What can you do to increase the frequency of time you spend in environments that contribute to your feelings of wellness?
  5. What can you do to create places or spaces in your mind that you can use (anywhere and anytime) to increase your sense of comfort and wellness in the moment?

Active Learning Assignment 4 – Three Good Things

Perhaps the most basic and well-known evidence-based happiness assignment is Martin Seligman’s Three Good Things activity.

Here’s Seligman’s description: Write down, for one week, before you go to sleep, three things that went well for you during the day, and then reflect on why they went well.

Just in case you want to hear it from the horse’s mouth, here’s a one-minute video of Seligman describing the activity: https://www.youtube.com/watch?v=ZOGAp9dw8Ac

For this assignment, you should do the Three Good Things activity for a week, as prescribed by Seligman. Dan and I don’t need to see all 21 good things from your whole week, but we would like you to share the following with us:

  1. Three ESPECIALLY good things from the week (think of these of as your Good Things Highlights). We’re very excited to hear about these.
  2. The most common (summarized) explanations for why these 21 good things happened. We’re very interested in what’s happening (or what you’re doing) to create the good things in your day-to-day lives.

 

 

Counseling and Psychotherapy Theory and Practice, Multicultural, Personal Reflections

Integrating Multicultural Sensitivity into CBT

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Woman Statue

A question and brief discussion on Twitter about integrating multicultural competence into CBT inspired me to look back and see what the heck we wrote for that section in our theories text. In the Twitter discussion, we agreed that Pam Hays’s work on CBT and multicultural content is good.

Here’s what I found in our theories text. Obviously it’s a short section and limited, but there are a few interesting points and a citation or two.

Cultural and Diversity Considerations in CBT

CBT focuses on symptoms as manifest within individuals. This position can be (and is) sometimes viewed as disregarding important culture, gender, and sexual diversity issues. For most cognitive-behavioral therapists, culture, gender, and sexuality aren’t primary factors that drive successful outcomes.

This position is a two-edged sword. In the featured case (in Chapter 8), Richard is a white male living a life squarely in the middle of the dominant culture. The therapist was committed to Richard’s well-being. If the client had been an Asian Indian or a bisexual or a woman experiencing domestic abuse the cognitive-behavioral therapist would have been equally committed to the client’s well-being. This is the positive side of CBT being less diversity-oriented.

The negative side is that CBT can be viewed and experienced as blaming clients for their symptoms, when the symptoms may be a function of diversity bias. D. Dobson and K. S. Dobson (2009) articulated the potential for clients to experience blame,

By virtue of looking for distorted thoughts, cognitive-behavioral therapists are more likely than other therapists to find them. Furthermore, some clients do react to the terms distorted, irrational, or dysfunctional thinking. We have heard clients say something to the effect—” Not only do I feel bad, but now I’ve learned that my thoughts are all wrong.” (p. 252)

Awareness of the possibility of client blaming is crucial. For example, what if Richard were a Black American male? And what if his therapist noticed that Richard’s thought record included numerous personalization examples? If so, instead of concluding that Richard is displaying oversensitivity and paranoid cognitions, his therapist should explore the possibility of microaggressions in Richard’s daily life.

The term microaggression was coined by Chester Pierce (1978). Microaggressions were originally defined as “the everyday subtle and often automatic ‘put-downs’ and insults directed toward Black Americans” but now this is expanded so they “can be expressed toward any marginalized group in our society” (Sue, 2010, p. 5).

Microaggressions are typically unconscious. For example, we had a female client come to us in great distress because her vocational instructor had told her “You’re pretty strong for a girl.” Although the vocational instructor defended his “compliment,” the young woman clearly didn’t experience the statement as a compliment. In this circumstance if a therapist is insensitive to culture and gender issues, the young woman might feel blamed for having irrational thoughts and overreactive behaviors. Sue (2010) recommends that mental health professionals exercise vigilance to address microaggression issues inside and outside of counseling. One way in which cognitive behavioral practitioners have addressed the potential for committing microaggressions against sexually diverse clients is by using LGBTQ affirmative CBT (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015).

Returning to racial/cultural microaggressions, let’s briefly pretend that Richard is a 6′7′′ Black American male. In his thought record he notes:

Situation: Walking into the local grocery store. Young female makes eye contact with me and then quickly turns around and goes back and locks her car.

Thoughts: She thinks I’m going to steal her car.

Emotions: Anger.

Behavior: I act rude toward her and toward other white people I see in the store.

If the Black American version of Richard has a therapist who looks at this thought record and then talks with Richard about the distorted thinking style of mind-reading (“Richard, you didn’t really know what she was thinking, did you?”) this therapist is showing cultural insensitivity and will likely be fired by Richard. This is an example of one of the many growing edges CBT should address with respect to women and minority clients.

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As always, your reactions to this content are welcome.

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections

Three Top Jokes from the Funniest Counseling and Psychotherapy Theories Text on the Planet

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Corey Wubbolding and SF

Rita keeps saying I’ve been laughing more. Last night we were watching an Australian soap opera featuring an overly aggressive goat. I got the giggles. Maybe it’s all this focus on happiness lately. Then again, we’re also writing a suicide assessment and treatment book, which partly translates into living in and cherishing every moment. So who really knows what’s up with me thinking angry goats are funny?

Last week I did a Zoom appearance in Dr. Julia Taylor’s theories class at the University of Virginia. As usual (this is my third year visiting her class), Julia had her students well-prepped; we had a fantastic discussion. One student, much to my delight, said our theories text was the funniest text ever, and that she learned more from it than she had in four years of reading undergraduate textbooks. I, of course, heartily agreed and thanked Elexus (I still remember her name) for her wonderful comments.

As a textbook writer, I don’t get a ton of positive feedback, but when I do, it tickles my heart and makes my day.

Today, after doing a private consultation with a mental health counselor in Denmark, I sent out a copy of the CBT chapter from our theories text. Before sending it, I read the first paragraphs, and laughed out loud. I’d forgotten that we somehow left my free associations about cognition in the chapter opening. I laughed partly because the prose was hilarious and partly because of a tinge of embarrassment that my irreverent writing might be just too much for some readers. Oh well. I hope not.

More importantly, reading that paragraph made me decide to feature three IMHO hilarious excerpts from our Counseling and Psychotherapy Theories in Context and Practice textbook (Yes, it’s funnier than it sounds, but then, that’s a very low hurdle). https://www.amazon.com/gp/product/1119473314?pf_rd_p=ab873d20-a0ca-439b-ac45-cd78f07a84d8&pf_rd_r=FT4RVJG8794EET839Y97

Excerpt One: Free Associating to Cognition

Chapter Eight starts with the following magic.

We have many ideas about how to open a chapter about cognition. John wanted to say something pithy like, “You are what you think,” but Ralph Waldo Emerson got there first. Rita was considering, “As a woman thinketh” (a feminist version of James Allen’s 1903 book titled, “As a man thinketh”), but John countered with “As a person thinketh” and by then we’d grown weary of the word thinketh. Then Rita waxed Shakespeare-esk, saying, “There is nothing either good or bad but thinking makes it so” which seemed a little better than the Buddha’s, “What you think you become” until we found the writings of Hafiz (a 14th century Persian poet):

Zero

Is where the Real Fun starts

There’s too much counting

Everywhere else!

(Ladinsky, 1996, p. 47)

Although Albert Ellis might respond to this poem by asking, “What the Holy Hell are you thinking,” we thought it was about clearing a cognitive space for meditation. Let’s start with zero.

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Okay. Just in case you’re not ROTFL now, here’s a clip from the existential chapter that will knock your socks off. This comes under the heading, “The I-Am Experience”

Excerpt Two: Existentialists and Hyphens

Existentialists like to use hyphens to capture the interconnectedness of phenomenological experience. For example, in contrast to May’s I-am experience, Boss (1963) and Binswanger (1933) used Dasein (which is translated to being-in-the-world) to describe the sense-of-existence. Also, the phrase, “Dasein choosing,” which is translated to the-person-who-is-responsible-for-his-existence choosing is used. We should note that this practice is in no way related to our own hyphenated last names, although it has inspired John to consider adding a hyphenated middle name so he can refer to himself in the third person as, “John-who-is-responsible-for-his-existence-Sommers-Flanagan,” which he thinks sort of rolls right off the tongue.

It follows, as-if-anything-really-follows-from-the-preceding, that existential therapy is nearly always in the service of self-awareness or self-discovery. However, unlike psychoanalysts, existentialists expand and illuminate client self-awareness rather than interpreting client unconscious processes. This is because existentialists believe the entirety of an individual’s human experience is accessible to consciousness.

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And now, the grand finale (although there are many more where these come from), and my personal favorite, from Chapter 11: Constructive Theory and Therapy

Excerpt Three: I’m Not Afraid of Philosophers

In this chapter, we de-emphasize distinctions between constructivist and social constructionist perspectives. Mostly, we lump them together as constructive theories and therapies and emphasize the intriguing intervention strategies developed within these paradigms. This may upset staunch constructivists or radical social constructionists, but we take this risk with full confidence in our personal safety—because most constructive types are nonviolent, strongly preferring to think, write, and engage in intellectual discussion. Therefore, within our own socially or individually constructed realities, we’ve concluded that we’re in no danger of bodily harm from angry constructive theorists or therapists.

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I’m sure many of you haven’t gotten the delight out of these hilarious counseling and psychotherapy theories humor that I have. Maybe that’s a sign that you too, should start studying happiness. On the other hand, reading theories books may have permanently warped my sense of humor. Either way, I hope you find sparkling moments and laughter here and there in your lives.

Counseling and Psychotherapy Theory and Practice

Draft Counseling and Psychotherapy Syllabus

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Below I’m including a drafty copy of our Counseling Theories syllabus from the University of Montana. My apologies for the wacky font action.

Theories III Photo

**Draft – 2016 Standards Alignment in Progress**

 COUN 511: COUNSELING THEORIES & TECHNIQUES

COURSE SYLLABUS – UNIVERSITY OF MONTANA – Fall 2019

____________________________________________________________

INSTRUCTOR INFORMATION HERE:

Office:

Office Hours:

Email:

SCHEDULED CLASS MEETINGS:  Class meets on Mondays from 4:00pm to 6:50pm, beginning Monday, August 26, 2019. The oral final exam for graduate students is TBA.

COURSE CONTENT AND DESCRIPTION:  This course is an overview of major theories of counseling and psychotherapy with a special focus on gender, culture, counselor preparation, and common theory-based assessment and case formulation strategies. Because the purpose of counseling and psychotherapy is to help individuals make personally meaningful changes in their lives, we will consistently examine the means through which traditional theories attempt to produce such changes. Students will read about historical and intellectual foundations of major counseling theories, while at the same time, observing skills and techniques employed by practitioners using those theoretical perspectives. There will be opportunities, through assignments and class discussions, for students to analyze clients as well as themselves through the various lenses of psychological theories. Overall, students are encouraged not only to explore all the major theoretical orientations, but also to explore their personal beliefs and values in an effort to develop and deepen their understanding of counseling and psychotherapy process and outcome.

TEXTBOOK:  Required: Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Counseling and Psychotherapy Theories in Context and Practice (3rd ed). Hoboken: NJ: Wiley.

Recommended: Sommers-Flanagan, J., & Sommers-Flanagan, R. (2012). Student manual for Counseling and Psychotherapy Theories in Context and Practice (2nd ed). Hoboken: NJ: Wiley.

COURSE OBJECTIVES: The purpose of this course is to introduce you to theories and techniques used by a variety of mental health professionals, school counselors, and other human service providers. We will explore and discuss the major theories and their practical application.

CACREP-Related Course Objectives: This course is a first Fall semester requirement for graduate students in Counseling at the University of Montana. The course includes content related to CACREP Core Standards and CACREP Specialty Standards. Specific key performance indicators are evaluated through course assignments, midterm and final examinations, and via an oral examination at the end of the semester. The oral examination focuses on the content of counseling theories and their application. The goals of the assessments in this course are to determine (a) how well the Counselor Education faculty is teaching specific CACREP-related objectives, (b) students’ ability to articulate and apply counseling theories, and (c) student readiness to enroll in counseling practicum (COUN 530).

DISABILITY ACCOMMODATIONS: If you are a student with a disability and wish to discuss reasonable accommodations for this course, contact me privately to discuss the specific modifications you wish to request. Please be advised I may request that you provide a letter from Disability Services for Students verifying your right to reasonable modifications. If you have not yet contacted Disability Services, located in Lommasson Center 154, please do so in order to verify your disability and to coordinate your reasonable modifications. For more information, visit the Disability Services website at www.umt.edu/dss/.

ACADEMIC INTEGRITY: All students must practice academic honesty.  Academic misconduct is subject to an academic penalty by the course instructor and/or disciplinary sanction by the University.  All students need to be familiar with the Student Conduct Code.  The Code is available for review online at http://www.umt.edu/vpsa/policies/student_conduct.php.

IN-CLASS BEHAVIOR STANDARDS AND LEARNING ENVIRONMENT: In the Department of Counseling and at the University of Montana we strive to establish and maintain a positive learning environment. The expectation is that we will strive to treat one another with respect . . . even when we disagree. This also means that students (and faculty) will turn off their cell phones and not engage in internet shopping/surfing/social networking during class. If calls and texting are necessary, you should either not attend class or take care of your calling and texting at class break. If you need to be on-call due to employment responsibilities, please let me know.

TEACHING METHODS:

1.  Lectures/class demonstrations.

  1. Guest lectures/student presentations.
  2. Video/DVD/Film presentations.
  3. Class activities.
  4. Class discussions.

GRADING PROCEDURES:  Grades are based on completion of class assignments, midterm and final examination scores, and class participation/attendance. Course assignments are listed and described in a separate section. The grading scale is below:

A   = 93%+                        B-  = 80-82%               D+ = 67-69%

  • = 90-92% C+ = 77-79%               D   = 63-66%

B+ = 87-89%                     C   = 73-76%               D-  = 60-62%

B    = 83-86%                    C-  = 70-72%               F    = Below 60%

APPROXIMATE SCHEDULE OF CLASS TOPICS AND ASSIGNMENTS

Week Date Assigned Reading In-Class Topic Assignments Due
1 8/26 Ch. 1

 

In future weeks, read chapters before class

 Syllabus distribution and introduction to counseling and psychotherapy.

 

 

 

 Be sure to login to the Moodle course supplement. This is mostly for communication and to give me something to complain about.
XX 9/2 None Labor Day No Class  
2 9/9

 

 Ch. 2 Psychoanalytic Theory and Therapy.

 

  
3 9/16 Ch. 3 Individual psychology and Adlerian therapy – Guest Lecture with Dr. Veronica “Roni” Johnson  
4 9/23 Ch. 4 Existential theory and therapy Initial theories reflection paper due, by midnight 9/22/19  (30 points)
5 9/30

 

 

 Review chapters 1-4 and lectures Midterm #1 – 1st hour: Covers chapters 1-4. [From 5:30pm to 6:50pm there will be a WHOLE CLASS skills lab focusing on person-centered therapy and mental imagery] Midterm #1 (50 pts)

Chapters 1-4 plus lecture material
6 10/7 Ch. 5 The person-centered approach.  
7 10/14 Ch. 6 Gestalt theory and techniques.  
8 10/21 Ch. 7 Behavioral theory and therapy.  
9 10/28 Ch. 8 Cognitive approaches (or CBT).  
10 11/4 Review readings and lectures. Midterm #2 – 1st hour.

Covers chapters 5-8, plus lectures. [From 5:30pm to 6:50pm there will be a WHOLE CLASS skills lab focusing on CBT.]

 Midterm #2 (50 pts).

Chapters 5-8, plus lectures
9 11/11 Ch. 9 Choice theory and reality therapy  
11 11/18 Ch. 10 Feminist theory and therapy.  
12 11/25 Ch. 11 Constructive theory and therapy.  
13 12/2 Ch. 13 and 14 Multicultural theory and therapy and Counseling integration. Final papers due by midnight on Friday, 12/6/19
14 Week of 12/9 Review readings and lectures. Final examination.

Covers chapters 9, 10, 11, 13, 14

 Final exam (50 pts). Chapters 9, 10, 11, 13, 14, plus lectures

The graduate oral final exam is TBD

OFFICIAL ASSIGNMENT DESCRIPTIONS

There are 290 possible points available (YOU CAN CHOOSE TO DO #3 A or B, BUT NOT BOTH).

  1. Two Midterm Examinations (50 points each; 100 total): These are standard multiple choice and short answer exams. They will cover material from all the lectures and chapters as outlined in the syllabus and worth 50 points each. You’ll be expected to take the exams at their scheduled times; if you have a time conflict, contact us in advance and we’ll set up an alternative exam time. If you have a last minute crisis (e.g., an accident, illness, or emergency) contact us ASAP and we’ll be flexible. In all cases, you’ll need to arrange a special time and sit for the exam within one week of the original exam date or you’ll get a zero. We will be flexible the first time. If a pattern of irresponsibility emerges, we’ll become less flexible and you’ll be required to take a much harder examination.
  1. Initial Theories Reflection Paper (30 points; see calendar for due date): This is a short paper designed to accomplish three objectives: (a) give you an opportunity, early in the course, to explore a concept from the text or from class in greater depth; (b) provide you with an initial, simple library-related assignment; (c) provide me with an early sample of your writing skills.

The paper can focus on virtually any topic addressed in class or covered in the first four chapters of the text. Here’s what you should do:

  • Select a topic: Sample topics include
    • The great psychotherapy debate
    • Informed consent
    • Multicultural competence
    • Doing no harm
    • The seduction hypothesis
    • Defense mechanisms
    • Feminism and psychoanalysis
    • Why children misbehave
    • Earliest recollections
    • Paradoxical strategies
  • Read the section in the text about that topic
  • Go to the library (or do an online search) and find a professional journal reference pertaining to your topic and then list it in APA format in the reference section of your paper.
  • Write a three page paper (following APA format) on your selected topic
  • In your paper write (a) a description of the topic or issue and why you think it is an especially important topic for beginning counselors; (b) additional information that you learned about the topic through your library research; (c) a reflection that includes critical comments about the topic/issue; and (d) some concluding comments about how this topic is relevant for you and your work in the future as a counselor

The paper will be graded in the following areas: (a) attention to detail/typos, etc. (3 points; 10%); (b) following APA format (3 points; 10%); (c) writing skills/grammar/organization (6 points; 20%); (d) general summary and accuracy regarding the topic chosen (12 points; 40%); (e) inclusion of some original and interesting thoughts about the topic (6 points; 20%).

  1. Choose ONE of the following assignments to complete:
    1. Theories or Cultural Book Review and Critique (50 points; see calendar for due date): The purpose of this assignment is for you, as an individual, to dive deeper into, and learn more about, a theory of interest to you. I have many books in my office that you can peruse for this assignment or you can go to the library or you can buy something on your own. After you’ve selected a book and check with me to make sure it’s acceptable, there are three parts to this assignment: (a) read your selected book; (b) write a four-page summary and critique of the book (include both a summary and critique—focusing on the book’s strengths and weaknesses as well as a description of how you will apply the information you learned from the book to your life in the future); and (c) be prepared to provide a ten-minute presentation on the book at our final class, although please note that book presentations may or may not happen depending on time – TBA. If they do, you should just say if you recommend the book to others and how you rate it on a 1-100 scale and engage the class in a brief demonstration of something you learned from the book.

Grading Procedures

This assignment is worth 50 points. To earn the 50 points you will need to turn in high quality work. You will lose points for typos, misspelled words, concepts that are defined poorly or used incorrectly, incomplete or unclear descriptions of the text. In particular, you will be graded on the quality of your summary and critique. Your summary will need to be accurate and show that you understand the content of the book. Your critique should show some sophistication of thought and reflection. Although your personal opinion is desired, you should also provide a critique based on a professional source (e.g., the text, a journal article, etc). Failure to cite at least one relevant reference linked to the book content will cause you to lose five points.

  1. Personal Change Project (50 points; see calendar for due date): The purpose of this assignment is for you to apply some sort of personal change strategy to yourself. Previously this was a purely behavior modification project, but due to diverse student interest, you can now engage in any personal change strategy you like.

The Details

You’ll be using APA Style. That means you’ll have the following sections:

  • Introduction: In this section you’ll introduce your target behavior and your rationale for choosing to change it. You’ll include a small bit of background research on different methods for potentially modifying your target behavior. This will require at least two professional journal citations (please, DO NOT cite online and unsubstantiated gibberish). Although you may have some incredible ideas yourself, the point is for you to NOT completely rely on your own idiosyncratic ideas about how to change your target behavior. For example, let’s say you chose to reduce your intake of sugar. There have been many books and articles written on diet change. I would expect you to read and reference a few of these.
  • Method: In this section you will identify and define a specific, measurable behavior that you would like to increase, decrease, or eliminate. This behavior is called your “target behavior.” For example, you might choose to increase exercise behavior. To begin this assignment, you need to have a clear, operational description of the behavior and a method for measuring the occurrence of the behavior. For example, if you select “push-ups” as your behavior to increase, you would need to define exactly what you meant by “push-up” and then detail a method for obsessively tracking (measuring) of your push-up behavior. Other behaviors people have chosen in the past include: (a) increasing dream recall; (b) decreasing cigarette smoking; (c) increasing smiling behavior; (d) decreasing fingernail biting behavior; (e) increasing study behavior, etc. Of course, I encourage you to identify what you want to change, rather than simply choosing one of the aforementioned target behaviors. The method also includes a description of your change plan. Describe it so well that it could be replicated. Your plan SHOULD NOT rely exclusively on your WILLPOWER. It should flow from your introduction or brief look at the scientific literature. When I grade your assignment I’m interested in the specific techniques you’ve gleaned from the text or outside readings. For example, if you’re using a behavioral approach, I’d look for you to use strategies like: (a) positive reinforcement; (b) punishment; (c) response cost; (d) negative reinforcement; (e) stimulus control; (f) stimulus generalization; (g) fading; (h) unconditioned stimulus; (i) conditioned stimulus, etc. If you choose to use a cognitive approach, consider using the three column technique, shades of gray, visualization, rational disputing, etc. Your method section includes the method through which you plan to make your changes. Please inform John of your target behavior before proceeding with the assignment. Email me at sf@mso.umt.edu or pass me a note in class informing me of your chosen behavior and general strategy. Tip: Don’t select an infrequent behavior because then it will take you several years to get done. Write a contract for yourself (e.g., “I Rita SF, do solemnly swear. . .”). Include the behavior, the plan, your goals, and a space for you and a witness (someone in your social environment) to sign and co-sign the contract.
  • Results: I’ll be looking for two main things in your results section. First, I want to see numbers or a chart or graph that you’ve used to track your target behavior. This will include a baseline measurement of your target behavior over at least one week. I need to be able to see and understand your progress or lack thereof. Second, to capture your qualitative experience, I want to see a weekly journal entry about how it’s going. Discuss your feelings, your personal experience and perspective, and why you think the project is working or not working. You can also modify your change plan during the semester, as long as you clearly identify how and why you’re going to change your approach in your weekly journal entry, also noting that in your results section. Remember that good counselors are very flexible and creative in their approach.
  • Discussion: The discussion is your reflection on the project. It focuses on “what happened” (the results) but also provides a platform for you to speculate on what helped, what didn’t, and why.
  • References: You need at least two professional citations in APA format.
  • Appendix: Include a signed (and countersigned) contract to yourself as a commitment to this behavior change project.

Grading Procedures

This assignment is worth 50 points. To earn the 50 points you will need to turn in high quality work. However, your grade on this project is NOT AT ALL based on your success or failure in changing your behavior.

You will lose points for typos, misspelled words, concepts that are defined poorly or used incorrectly, incomplete or unclear descriptions of what you did and what happened, etc. Failure to cite at least a couple of relevant studies, articles, or books will also lose significant points. Follow the outline and you’ll have a good start. Please do your best work. Good luck and have fun!

  1. Attendance (30 points): We’ll take attendance at every class. Perfect attendance is worth 30 points. You’ll lose an increasing number of points for each class missed (even if you miss class for legitimate reasons). You lose 0 points for missing one class (everyone deserves a mental health day), 6 points for missing two classes, 9 more (total = 15) for the third, 15 more (all 30 points are lost) for the fourth. There will be in-class reflection assignments. If you don’t turn these in or do a poor job you’ll lose attendance points. To be fair, you can earn back points from missing class by completing additional assignments. You can earn attendance points back by listening to recorded lectures (as available), contacting Kindle Lewis (the TA) who will give you an additional assignment (e.g., writing an essay or responding to several lecture-related questions). Alternative assignments may be used at our discretion. If you’re motivated you can recover lost points.
  1. Graduate Skills Lab (30 points): All students enrolled in COUN 511 or taking the course for graduate credit will participate in a Counseling Skills Lab. We will break into smaller groups for this and the exact time and place for the lab is TBA. It will consist of 6-8 meetings (two of which will be after the first midterm) during which you practice the skills associated with specific theories on each other. We will start communicating about lab meeting times during the first week of the semester. If you miss one Grad Lab, you lose 15 points. If you miss two Grad Labs, you lose all 30 points.
  1. Final Oral Examination (50 points): For all graduate students, you will sit for a small (about 10 students) 90 minute group examination. You will be given short answer questions and a role-play assignment at least one week prior to the exam to help you prepare and study. During the exam, you’ll be asked, at random, several questions from the questions you’ve been given (and hopefully have studied) and you’ll be asked to demonstrate via role-play several skills associated with at least one theoretical orientation. This exam format is designed to help you learn to orally articulate and apply some of the theories concepts we’ve studied during the semester.

CACREP KPIs for Core and Specialty Counseling Competencies

All courses in the Department of Counseling include content related to our national Counseling and Counseling-Related Educational Programs (CACREP) accreditation. CACREP identifies specific Core Standards as well as Specialty Standards. The following Table includes a listing of the CACREP Core and Specialty Standards covered by COUN 511 course content. Additionally, some of the standards listed below are the focus of Key Performance Indicators (KPIs). KPIs are specific CACREP standards that are systematically evaluated in order to determine whether students are learning key CACREP-related course content. In this course (COUN 511), the KPIs are evaluated through using the course assignments, experiential laboratory activities, midterm and final examinations, and via an oral examination at the end of the semester.

Core Standard Content Found Key Performance Indicator
2. SOCIAL AND CULTURAL DIVERSITY    
b. theories and models of multicultural counseling, cultural identity development, and social justice and advocacy

 

 COUN 511 – Students read about how each theory addresses culture, sexuality, and spirituality.

 
c. multicultural counseling competencies

 

 COUN 511 – Students read about the MCCs in Chapter 1 and Chapter 13 of the textbook

 

  
d. the impact of heritage, attitudes, beliefs, understandings, and acculturative experiences on an individual’s views of others

 

 COUN 511 – Students read about this content in Chapter 13 and participate in a classroom activity.

 

  
5. COUNSELING AND HELPING RELATIONSHIPS    
a. theories and models of counseling

 

 COUN 511 – Students read about theories and models of counseling in their textbook and practice techniques linked to the theories in their counseling labs. Two midterm examinations and one oral final examination are used to measure student knowledge three times during the course.
b. a systems approach to conceptualizing clients

 

 COUN 511 – Students read about systems approaches in Chapters 11 and 12.  
f. counselor characteristics and behaviors that influence the counseling process

 

 COUN 511 – Students read about specific counselor characteristics and behaviors that influence counseling process and outcomes in the textbook.

 

  
g. essential interviewing, counseling, and case conceptualization skills

 

 COUN 511 – Students read about how to engage in case formulation and treatment planning in every theories chapter of the textbook.

 

  
h. developmentally relevant counseling treatment or intervention plans

 

 COUN 511 – Students read about counseling theories, treatments, and interventions that are more or less useful with specific developmental populations in the textbook.

 

 None
i. development of measurable outcomes for clients

 

 COUN 511 – Students read about measuring outcomes in every theories chapter of the textbook.

 

  
j. evidence-based counseling strategies and techniques for prevention and intervention COUN 511 – Students read about evidence pertaining to counseling strategies and techniques associated with each theory in the textbook.  
n. processes for aiding students in developing a personal model of counseling COUN 511 – Students read about how to integrate their personal ideas with existing theoretical models in the textbook. Students take a theoretical orientation test and write a one-page reflection on their initial preferred model of counseling.
8. RESEARCH AND PROGRAM EVALUATION    
a. the importance of research in advancing the counseling profession, including how to critique research to inform counseling practice

 

 COUN 511 – Students read about research linked to each theory presented in the textbook.  
b. identification of evidence-based counseling practices

 

 COUN 511 – Students read about evidence-based counseling practices in every chapter of the textbook.  
d. development of outcome measures for counseling programs

 

 COUN 511 – Students read about theory-based counseling outcome measures in every theories chapter.

 

  
e. evaluation of counseling interventions and programs

 

 COUN 511 – Students read about theory-based counseling outcome measures in every theories chapter.

 

  

 

 

 

 

 

 

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

The Evidence Base for Psychoanalytic Therapies: It Just Might Be Better Than You Think

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Sunset 2019In recent days there’s been a bit of a kerfuffle on Twitter regarding the relative efficacy of psychoanalytic and cognitive-behavioral therapies (CBT). Of course, the standard mantra in the media and among many mental health professionals is that the science shows that CBT is superior and the treatment of choice for many, if not most, mental and emotional problems. Well, as is often the case in life and psychotherapy, reality is much less clear.

This post isn’t about fake news or alternative facts. Instead, I hope it’s about a balanced perspective. As a psychotherapist-counselor-professor-clinical psychologist, I like to think I don’t have an allegiance to any single therapy approach. Although I know I can’t claim perfect objectivity, I do have a broad view. One factor that has helped me have a broad view is that I read lots of professional journal articles in order to be able to write my theories of counseling and psychotherapy textbook.

Below, I’ve inserted an excerpt from the end of the psychoanalytic chapter of our textbook. Whether you’re a CBT or psychoanalytic fan, or perhaps a fan of a different approach, I hope you find this short review of psychoanalytic treatment efficacy interesting. The bottom line for me is captured by an old quotation from Freud (who wasn’t known for his flexible thinking). Purportedly, he said, “There are many ways and means of conducting psychotherapy. All that lead to recovery are good.” I might add the following to Freud’s comment: There are many different clients with many different problems and many different individual and cultural perspectives. I’m convinced that most clients are best served if therapists tweak their approaches to fit the client, rather than expecting the client to fit into narrow clinical procedures based on pure (or rigid) theoretical perspectives.

Here’s the excerpt . . .

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

Conducting rigorous research on longer-term treatments, such as psychoanalytic therapy, is challenging and cost prohibitive. Psychoanalytic approaches are often less symptom- or diagnosis-focused, seeking instead to facilitate client insight and improve interpersonal relationships. Because empirically supported treatments focus on whether a specific psychological procedure reduces symptoms associated with a medical diagnosis, “proving” the efficacy of complex therapy approaches is difficult—especially when compared to the lesser challenges inherent in evaluating symptom-focused treatments. Partly because of these complexities, some reviewers contend that psychoanalytic psychotherapies are less efficacious than cognitive and behavioral therapies (Busch, 2015; Tolin, 2010).

The good news for psychoanalytic therapy fans is that evidence is accumulating to support treatment efficacy. The less good news is that some of the research support remains methodologically weak and the wide variety of psychoanalytic approaches makes it difficult to come to clear conclusions. Nevertheless, the most recent meta-analytic studies, literature reviews, and individual randomized controlled studies support the efficacy of psychoanalytically oriented therapies for the treatment of a variety of mental disorders. According to Leichsenring, Klein, and Salzer (2014), there is empirical support for the efficacy of psychoanalytic psychotherapies in treating:

  • Depressive disorders.
  • Anxiety disorders.
  • Somatic symptom disorders.
  • Eating disorders.
  • Substance-related disorders.
  • Borderline personality disorder.

The evidence for the efficacy of psychodynamic approaches for depressive disorders is strong. In a recent meta-analysis, Driessen and colleagues (2015) evaluated 54 studies, including 3,946 patients. They reported that short-term psychodynamic psychotherapy (STPP) was associated with improvements in general psychopathology and quality of life measures (d = 0.49–0.69) and all outcome measures (d = 0.57–1.18); they also noted that patients continued to improve at follow-up (d = 0.20–1.04). Further, no differences were found between STPP and other psychotherapies. On anxiety measures, STPP appeared significantly superior to other psychotherapies at post-treatment (d = 0.35) and follow-up (d = 0.76).

In a previous meta-analytic review, Shedler (2010) also concluded that psychodynamic therapies were equivalent to “. . . other treatments that have been actively promoted as ‘empirically supported’ and ‘evidence based’” (p. 107). He also reported that psychodynamic therapies had more robust long-term effects.

Table 2.2 provides a sampling of meta-analytic evidence supporting psychodynamic therapies. For comparison purposes, the original meta-analyses conducted by Smith and colleagues are included (Smith & Glass, 1977; Smith et al., 1980). Notably, Smith, Glass, and Miller reported that psychodynamic approaches were significantly more efficacious than no treatment and approximately equivalent to other therapy approaches.

Table 2.2 also includes the average effect size (ES or d; see Chapter 1) for antidepressant medications (ES = 0.31 for serotonin-specific reuptake inhibitors or SSRIs). This comparison data shows that psychodynamic psychotherapy is more effective than SSRI treatment for depression. Additionally, the benefits of psychoanalytic therapy tend to increase over time (Driessen et al., 2015; Shedler, 2010). This implies that psychoanalytic psychotherapy clients develop insights and acquire skills that continue to improve their functioning into the future—which is clearly not the case for antidepressant medication treatment (Whitaker, 2010). One of the ways psychotherapists explain this difference in longer term efficacy is with the statement: “A pill is not a skill.”

Table 2.2 A Sampling of Psychodynamic Psychotherapy Meta-analyses

Authors Outcome focus Number of studies ES or d
Abbass et al. (2009) General psychiatric symptoms 8 0.6
Anderson & Lambert (1995) Various 9 0.85
de Maat et al. (2009) Long-term treatment 10 0.78
Driessen et al. (2015) Depression 54 0.57–1.18
Comparison research
Turner et al. (2008) Meds for Major depression 74 0.31
Smith et al. (1977) Different therapies 375 0.68
  Many problems    
Smith et al. (1980) Different therapies 475 0.75
  Many problems    

Note: This is a sampling of meta-analytic psychoanalytic psychotherapy reviews. We’ve omitted several reviews with very high effect sizes partly because of criticisms related to their statistical methodology (see Driessen et al., 2015, and Shedler, 2010, for more complete reviews). This table is not comprehensive; it’s only a reasonable representation of psychoanalytic psychotherapy meta-analyses.

We recommend you take the preceding research findings (and Table 2.2) with a grain of salt. Conducting systematic research on something as subjective as human mental and emotional problems always includes error. One source of error is the allegiance effect (Luborsky et al., 1999). The allegiance effect is the empirically supported tendency for the researcher’s therapy preference or allegiance to significantly predict outcome study results.  Luborsky and colleagues (1999) analyzed results from 29 different adult psychotherapy studies and reported that about two thirds of the variation in outcome was accounted for by the researcher’s theoretical orientation (e.g., psychoanalytic researchers reported more positive outcomes for psychoanalytic therapy and behavior therapists discovered that behavior therapy was more effective).

The implications of the allegiance effect help explain why, shortly after Shedler’s (2010) publication extolling the virtues of psychodynamic psychotherapy, several critiques and rebuttals were published (Anestis, Anestis, & Lilienfeld, 2011; McKay, 2011). The critics claimed that Shedler’s review was biased and accused him of overlooking weaknesses within the meta-analyses he reviewed (e.g., poor outcome measures, pooling the effects of small samples with little power and poor designs, lack of treatment integrity effects). Although Shedler’s critics raised important points, the critics themselves had their own biases. The problem is that all researchers (and writers) have an allegiance of one sort of another.

One of our favorite ways of understanding the allegiance effect is articulated in a story about the great New York Yankee baseball player, Yogi Berra. One day, when a player on Yogi’s team was called out on a close play at second base, Yogi went charging on to the field to protest. The umpire explained that he, unlike Yogi, was an objective observer and that he, unlike Yogi, had been only about 5 feet from the play, while Yogi had been over 100 feet away, in the dugout. When Yogi heard the umpire’s logic, he became even angrier and snapped back, “Listen ump, I wouldn’t have seen it, if I hadn’t believed it” (adapted from Leber, 1991).

The “I saw it because I believed it” phenomenon is also called confirmation bias (Masnick & Zimmerman, 2009; Nickerson, 1998). Confirmation bias involves seeking, interpreting, and valuing evidence that supports pre-existing beliefs, while ignoring and devaluing evidence contrary to preexisting beliefs. Consequently, psychoanalytically oriented individuals see support for their perspective and behavior therapists see support for theirs. However, despite these caveats, based on accumulating research, psychodynamic approaches have a reasonably good record of efficacy.

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

Although this particular review has many limitations, I’m convinced that most of us, most of the time, are better off following the advice of Marvin Goldrfried (and others) and focusing on the common therapeutic factors, or, as Norcross calls a subset of common factors, empirically-supported relationships.

For more information, check out Goldfried’s recent article on obtaining consensus in psychotherapy:  https://www.stonybrook.edu/commcms/psychology/_pdfs/clinical/Goldfried%20AP%20Consensus%20AP.pdf

 

Cool Counseling, Parenting

Fear, Anxiety, Loathing, and Today’s Workshop for the Thriving Institute

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Even though I’m a Montana Grizzly, being back in Bozeman is always nice. Today, Rita is insisting that we go out to Burger Bobs before my evening workshop for the Thriving Institute. To be honest, Burger Bobs sounds a little heavy for my pre-workshop meal. I’m nervous, but I guess we’ll see if that’s a mistake or not.

For those in attendance (or those not in attendance), here’s the ppts for tonight. They’re like, “amazing” or at least I hope you think so.

Thrive Anxiety Beast 2019

Anybody feeling anxious? Or like a beast?

Spidey

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections

Two Announcements: A New Article on EBRFs and a New Milestone

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Coffee

Two things.

First, Kim Parrow, a doctoral student at the University of Montana emailed me a copy of our hot new journal article. The article explores evidence-based relationship factors as an exciting focus of research, practice, and training in Counselor Education. The article is published in the Journal of Mental Health Counseling. Here’s a link so you can read the article, if you like: EBRFs in JMHC 2019

Second, today when I logged into my WordPress blog, something seemed different. As it turns out, my official number of followers had turned from 999 to 1,000. I’m not sure what that means, other than a woman named Shaina from Thrive has won a special prize. Maybe I’ll see you on Thursday evening Shaina.

I hope you’ve all had a great day, especially all the veterans out there, who IMHO deserve deep appreciation for their service.