Tag Archives: Counseling

Clinical Interviewing, Suicide Assessment and Intervention

Assessment and Intervention with Suicidal Clients: A Brand New 7.5 Hour Video Training

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Yellow Flowers

Suicide rates in the U.S. are at a 30 year high. Beginning in 2005, death by suicide in America began rising, and it hasn’t stopped, rising for 12 consecutive years.

Worldwide (and at the CDC) suicide rates are tracked using the number of deaths per 100,000 individuals. Although the raw numbers listed above are important (and startling), calculating deaths per 100,000 individuals provides a consistent per-capita measure that allows for systematic comparison of suicide rates across different populations, geographic regions, sexual identity, seasons of the year, and other important variables. For 2000, the CDC reported an unadjusted death by suicide rate of 10.4 persons per 100,000. For 2016, they reported 13.7 suicides per 100,000 Americans. This represents a 31.7% increase over 16 years.

As suicide rates have risen, federal, state, and local officials haven’t been idly standing by, wringing their hands, and wondering what to do. To the contrary, they’ve been actively engaged in suicide prevention. In 2001, the Surgeon General established the first National Suicide Prevention Strategy, revising it in 2012. All the while, there have been big pushes by federal and state governments, community organizations, schools, private businesses, and nonprofits to fund and promote suicide prevention programming. For the most part, the suicide specialists who run these programs are fantastic. They’re dedicated, knowledgeable, and passionate about saving lives. In addition to all the prevention programs available today, currently there are more evidence-based psychotherapies for suicidal people than ever before in the history of time.

But even in the face of these vigorous suicide prevention and intervention efforts, suicide rates continue to relentlessly rise . . . at an average rate of nearly 2% per year.

At this point it’s clear that prevention efforts may not have a direct influence on overall suicide rates. It’s tough to move the big needle that measures U.S. suicide rates. Some solutions may be more sociological and political. Of course, that doesn’t mean we should stop doing prevention. But, given the numbers, it’s important for us to try to find alternative methods for reducing and preventing suicide.

All this leads up to an announcement. Today, Psychotherapy.net published a three volume 7.5 hour video training titled, Assessment and Intervention with Suicidal Clients. This project was a collaboration between Rita, me, and Victor Yalom (along with his amazing staff at Psychotherapy.net). Although watching this video won’t automatically make suicide rates decrease, gaining awareness, knowledge, and skills on suicide assessment and intervention is one way counselors and psychotherapists can contribute to suicide prevention.

Psychotherapy.net is offering an introductory offer for the 7.5 hour video, with CEUs included. You can click here for details on the introductory offer and a sneak peek at the video.

I hope you find the video training helpful, and I look forward to hearing comments and feedback from you about how we can keep working together to help prevent suicide.

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Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Internship Class Reflections

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Evening in M 1

Due to my poor time management skills, I ran out of time for comments during my Tuesday internship class. This error provided a sudden inspiration to continue making comments to my students via email. I asked their permission and they seemed interested. It reminded me of a technique Rita used to use when running groups. Following every group, she would write her own insightful reflective comments and send them out to the group members.

Here’s what I shared with me students . . . with . . . of course . . . all identifying information removed.

***********

In class I mentioned that I wanted to email you some ideas I didn’t have time to share . . . so here we go.

Based on the small amount of recording we listened to together, it sounded like our rock star counselor-in-training (aka “Rocky”) has established an excellent “relationship” or working alliance with her client. That being the case, many things are possible.

The first thing is what I already mentioned at the very end of class. Using her relational connection as a foundation, Rocky can use any of a number of strategies to open up a discussion about her changing her approach to less listening and more engagement. This doesn’t mean I think Rocky “should” be more active, but because Rocky feels it to some degree and brought it up with us, it’s a signal to me that it might be an issue worth exploring. Here’s an example:

“I’ve been thinking about how I act during our counseling sessions. Sometimes I notice myself sitting back and listening as you tell me a story about your life. I think the stories are important, so I mostly just stay quiet and listen. But I’m also wondering if, because the stories are important parts of your life, if maybe I should be more active and engaged with you as you share your stories with me. It might be better for me to ask questions, make comments, or try to identify patterns. If it’s okay with you, I’d like to talk a bit more. Would you be okay with that? If I try it and you don’t like it, we can always switch back.”

This way of bringing up the issue places the focus on Rocky’s behavior and it models how part of counseling involves self-reflection/analysis. It also introduces the idea as an experiment that both Rocky and her client can comment on.

The second issue I wanted to discuss more is the client’s reluctance to “get into her emotions.” Of course, this is a very common reluctance. If we look at it through a motivational interviewing lens, it’s very possible for her to be ambivalent about getting emotional. Part of her can see the value and part of her is afraid or reluctant.

One possible strategy, among many, is for Rocky to affirm that it’s okay to avoid talking about emotions (at least for now), but that in the meantime, it might be helpful to explore what makes talking about emotions feel so challenging. The point is to focus on “what gets in the way” of talking about the emotions directly first, and only then, after greater understanding is obtained, possibly move forward and experience the emotions.

Using this strategy, the assumption is that there are negative expectations (cognitions) linked to directly feeling/experiencing emotion. One of the following could be possible: (a) “I’m afraid once I open the emotional box, I won’t be able to stop” (then you explore if this has happened and examples of how she has recovered after being emotional in the past); (b) “I’m worried that you’ll judge me” (then you explore the possibility of that happening; (c) “I feel weak when I get emotional” (this might inspire a discussion about whether facing emotions directly is an example of being weak or being strong, or something else).

These are just some examples of the thoughts/expectations that can interfere with emotional processing. Many other unique scenarios are possible. In my experience, if you use collaborative empiricism to explore negative expectations, sometimes the expectations can be managed . . . and sometimes clients will spontaneously start talking about the benefits of emotional expression.

My last idea is related to a component part of EMDR. When clients have an image or situation linked to a specific trauma, EMDR practitioners employ two questions that are IMHO quite powerful. Here they are, using a made up scenario:

  1. “When you imagine the scene at your mother’s funeral, what negative belief about yourself comes into your mind?”

You might have to repeat that question because it’s complicated. The assumption here is that the trauma memory is linked to a core negative belief about the self.

Then you move to the opposite question:

  1. “When you imagine the scene at your mother’s funeral, what positive belief about yourself would you rather have come into your mind?”

You don’t have to be using EMDR to find your client’s answers to these questions very useful. The first answer is the disturbing or dysregulating belief. It needs desensitizing or disputing or something. The second answer is a new belief about the self that may constitute a major therapeutic goal. It needs supporting; it needs to become a possibility.

So . . . how do you get there? Well, I’d go on, but we need to have something to talk about next week:).

Have a great evening.

John

 

Counseling and Psychotherapy Theory and Practice

News Flash: The 3rd Edition of Counseling and Psychotherapy Theories in Context and Practice is Now Available!

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Theories III Photo

Hello Theories Fans.

I have exciting and good news! The third edition of Counseling and Psychotherapy Theories in Context and Practice is NOW AVAILABLE. Here’s the publisher’s link: https://www.wiley.com/en-us/Counseling+and+Psychotherapy+Theories+in+Context+and+Practice%3A+Skills%2C+Strategies%2C+and+Techniques%2C+3rd+Edition-p-9781119473312

The “less good” news (as the MI folks like to say) is that I wrote up a promotional piece for our publisher to distribute, but they thought it was TOO POSITIVE:) . . . so I’ll do what I can to temper my enthusiasm here.

What’s new in the Third edition?

Other than a massive reference overhaul, empirical updating, and re-writing and editing in response to reviewer feedback, the biggest news is that we added sections Sexuality, Neuroscience, and Spirituality.

The other good news is that our book (2nd edition) already had the highest average Amazon customer rating of all Counseling and Psychotherapy Theories texts, a whopping 4.6 out of 5.0 stars! [for comparison, 4.6 is the same rating as John Grisham’s “The Firm” and higher than Mary Pipher’s “Reviving Ophelia” . . . although, not surprisingly, Grisham’s and Pipher’s works tend to get a few more reviews]

It’s also important to note that our textbook is still relatively inexpensive (compared to other Theories textbooks).

This text also has excellent ancillaries. There is an accompanying video, test bank, online instructor’s resource manual, and a student study guide. The video clips are imperfect and spontaneous demonstrations of specific counseling skills that include counselors and clients with various cultural backgrounds.

Rita and I are humbled and happy to have the opportunity to publish the third edition of our Theories text with John Wiley & Sons. As in previous editions, our primary goal has been to translate complex theoretical material into prose that is engaging, reader friendly, easy to understand, and has a practical/skill-building emphasis. Most, but not all, of the reader reviews on Amazon are affirming and give us hope that we’ve accomplished this goal. To capture some of the positive responses, I’m sharing several Amazon reviews below:

  • The best text book I’ve ever read! Thoroughly enjoy the humor. Each chapter is written slightly different to capture the feel of the theory it describes. Laughed out loud at the final fantasy writing.
  • I love the writers of this book, it is like a conversation and sometimes humorous. Got the book right away.
  • Absolutely amazing read! Every line has important information and I actually enjoy when chapters are assigned for my theories class in this book!
  • While this was purchased for a class, I am really enjoying the information and case studies the author’s present. I do not mind reading this material and think this is one textbook I will not sell back to the bookstore, instead using it for reference throughout my new career.
  • This book was incredibly helpful to me as a counseling student. This is my first semester in the counseling program and this book was full of useful information, very easy to read and understand, and provided a vast overview of the different theories. I will definitely be keeping this book to use as a resource on future papers.

To see all 43 reviews, you have to go to the 2nd edition: https://www.amazon.com/Counseling-Psychotherapy-Theories-Practice-Resource/dp/1119084202/ref=sr_1_1?ie=UTF8&qid=1527631412&sr=8-1&keywords=John+Sommers-Flanagan

And here’s the 3rd edition on Amazon: https://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1119473314/ref=pd_cp_14_2?_encoding=UTF8&pd_rd_i=1119473314&pd_rd_r=229a780b-638c-11e8-890c-a735446468c0&pd_rd_w=A4Hos&pd_rd_wg=zISf0&pf_rd_i=desktop-dp-sims&pf_rd_m=ATVPDKIKX0DER&pf_rd_p=80460301815383741&pf_rd_r=SY3RS8RHYZYD8HPR7W7Y&pf_rd_s=desktop-dp-sims&pf_rd_t=40701&psc=1&refRID=SY3RS8RHYZYD8HPR7W7Y

As always, let me know if you have questions or comments on this post or on our third edition of Counseling and Psychotherapy Theories in Context and Practice.

Sincerely,

John SF

 

Suicide Assessment and Intervention

An Early Peek at the Suicide Assessment and Intervention Video Project

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Helicopter CroppedBack in March, 2012, I settled into a Starbucks in Vancouver, Washington to reflect on my experiences at the annual American Counseling Association conference in San Francisco. Memories of Dr. Irvin Yalom’s keynote bubbled up in my mind, so that’s what ended up in my fingers, on my screen, and in my blog.

Several days later, I got an email from a “Dr. Yalom.” Seeing the name, I immediately felt anxiety and anticipation. First thoughts, “I meant to be positive. I hope I didn’t write anything offensive?”

The email was from Dr. Victor Yalom. It was nice . . . and supportive . . . and positive . . . and a big relief.

Victor is the owner/publisher/president or grand sultan of psychotherapy.net. Psychotherapy.net is a publisher of psychotherapy training and continuing education materials, mostly videos. Over the past 6 years Victor and I have struck up a collegial friendship. He is the biggest fan and proponent of our Clinical Interviewing video series (which he sells through psychotherapy.net). After viewing the Clinical Interviewing video, he has repeatedly asked Rita and I about doing a video for psychotherapy.net. Unfortunately, the timing never worked out, until this past fall, when we agreed to collaborate on a six-hour suicide assessment and intervention training video.

As they say in the film industry, everything is in the can. We’re down to final editing and other details. We filmed in Missoula and Mill Valley. Rather than working directly with imminently suicidal clients, we got volunteers to channel previous or potential suicide-related experiences. All this is just my way of introducing this sneak peek into this upcoming video.

Of course, reading isn’t the same as watching, but the next 2,000 words can give you a glimpse of one of the cases featured on the video. The client is a young Native American man and veteran. Many cultural issues emerge during the session, along with suicide ideation. Here’s the clip, along with my side “commentary” in bold:

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John:            Cory, I know a little bit about you, but not very much. And so maybe the best place to start is for you to tell me some things about yourself, some things about how you’ve been feeling in your life, some things about the situations that you’ve been in, and maybe help me get a sense of how I might be of help.

Cory:            Yeah, I come from a small reservation in Eastern Montana, and I was kind of – it was a comfortable life growing up. I didn’t know anything different. And I remember sitting there with my family watching the war and kind of spurred us to want to help bring honor to our tribe. So, I signed up at 17.

John:            Yeah, what tribe?

Cory:            I’m from the Lakota Sioux tribe from the Fort Peck Indian Reservation.

John:            Okay. Great, thank you. Sorry.

Cory:            So, I left at 17, and it was kind of a big deal. We had a big honor, big gathering for me, big sendoff, and it was pretty great and feeling pretty good. Deployed when I was 18 years old over to Iraq. It was going great. I felt like I was doing something. I didn’t get to talk to my family much, maybe every three months. And I didn’t know what was going on at home. Had a fiancée when I left. Life was great. Eventually time to come home and came home. And my family’s kind of in disarray. My grandma died. I didn’t get to go to her funeral. They didn’t tell me.

John:            Yeah.

Cory:            So, kind of tore me up. My fiancée left me for one of my best friends, so that was the shock of my life.

John:            Yeah. So, at least at this point I’m hearing that you were on kind of a high and feeling good at 17, get a big sendoff from your tribe, from your family, and you go, and you go to Iraq. And you get back, and things are a mess.

Cory:            Yeah. Meth kind of hit our reservation pretty hard. And family members on meth and prison and kind of whole world changed, I guess. Eventually, I didn’t – just came back and started drinking. Not sure who I was anymore. So, that was difficult, didn’t have very many people to turn to anymore. Never had a father growing up. My mom was always raising us with a couple jobs. And eventually her and her boyfriend got into drugs, so that’s kind of pretty difficult. And I didn’t know what to do anymore. And I was kind of feeling down and just kept drinking, and I kind of don’t know what to do anymore. For us it’s a honor to serve and kind of makes us who we are.

John:            Yeah.

Cory:            We view it as becoming a warrior man.

John:            Yeah.

Cory:            And I felt like I did that, and I’d bring honor back to my culture, my tribe. Yeah, just I came home. Everything’s in disarray, and I thought I was pretty stable. Eventually – and one thing, on the reservation we don’t – or culturally we don’t talk about our feelings or emotions. So, every time we do, feel pretty shame. A lot of shame comes from it. So, it’s kind of you just deal with it.

John:            Yeah, yeah. Yeah, so a couple of cultural pieces. One is that sense of honor of serving, and you hooked onto that and were living that. And then another cultural thing is, it’s a little shameful to express emotions, sadness, that kind of emotion or others.

Cory:            Yeah, I mean, I guess I could just describe it as shame. Like I feel guilty talking about it because we’re supposed to be men.

John:            You’re warriors. You’re strong.

Cory:            Yeah.

John:            And so you keep it all –

Cory:            Yeah, it’s part of who we are, death, fighting, honor, celebrating together, just part of who we are.

John:            Yeah, yeah. And then as you get back, and you’re in this disarray, and the meth on your reservation is prevalent, and you start drinking, and it sounds like that could be connected with the emotional warrior. Is that one of the ways that you might cope?

Cory:            I guess I just – kind of just helped me feel nothing.

COMMENTARY: Cory has covered lots of ground quickly. He has articulated his collectivist identity. Knowing about his collectivist identity early in the session is a very good thing. He has also mentioned multiple stressors and losses; these stressors and losses are traditional risk factors and load onto the various risk dimensions. These include: coming back from war, being a veteran, loss and betrayal by his girlfriend, his grandmother’s death, the disarray of his tribal community from meth, and other issues. In addition, one immediate challenge that’s coming into my mind is how to address alcohol, because it’s a suicide desensitizer, but it’s also helping him “feel nothing” which is consistent with his cultural value of not expressing his feelings. At this point I’m choosing to build a relationship with Cory before jumping in and discussing alcohol directly.

John:            Okay.

Cory:            Just kind of, I guess, how I dealt with it because I couldn’t talk about stuff that happened over there, and I didn’t have no male role models in my life to kind of talk about culturally with or anything.

John:            Yeah. So, I’m aware of the fact that you’ve told me, and I really appreciate it, some cultural things about you, about being a Lakota Sioux, about the reservation that you grew up on and some of the things you experienced, about the honor, about the shame, about the warrior mentality. And I’m going to do my best to track all those things. Occasionally if you think I’m just not getting it from your cultural perspective, I would love it if you would tell me, but I don’t want to put all that responsibility on you. So, I will probably every once in a while just check in to see, am I getting this right? Is that okay with you if we –

Cory:            Yeah, that’s fine.

John:            Yeah, because I just don’t want to misunderstand things because of my lack of the same cultural experience as yours. And so as I’m imagining it, you’re back. You’re drinking. It’s part of being numb.

Cory:            Uh-huh.

John:            And getting rid of those emotions. And as you talk, one question that comes to mind to me, and my guess is that this would be a dishonorable thought to have, although not an abnormal thought because it’s not unusual when people come back and life is disappointing and hard, and you’re drinking, and you’re managing those emotions, it’s just not unusual to have a thought about suicide or about killing yourself. And my guess is that would be in opposition to your culture, too, but I don’t know.

Cory:            Yes and no. One way we look at is from we’ve had everything taken from us. That’s one thing you can’t take from us. Our life is ours to give to the Creator, to Wakan Tanka which is our God. So, when it’s our time, it’s kind of our choice.

John:            Okay.

Cory:            The sad thing about it is, I’m feeling down, and a lot of times like as I grew up I had – I was probably nine years old. My first friend committed suicide. And it brings the community together. We have big honoring, big feast for his family, for him, and just days of celebrating. It’s kind of like bring the family back together. I had another friend do it after that because he was – couldn’t graduate high school and didn’t have nobody there, and he wanted his family to come back together, so he committed suicide, just felt like it’s going to bring his family back together. And it did for a bit, but meth came in again, so it kind of tore it apart.

John:            Uh-huh.

John:            So, I’m hearing two suicides of people that you knew well around the time that you graduated high school?

Cory:            Oh, one was when I was 9, and a good friend was 16. And by the time I was 18, I probably lost maybe 7 friends from drinking and driving, drugs, stabbings. So, I guess to us, I mean, death is death, so it wasn’t really a big deal, kind of a celebration and we’ll see them again.

John:            Yeah. So, for each one the family celebrates, the community celebrates –

Cory:            Uh-huh.

John:            – the life. And sometimes it almost sounds like somebody might choose suicide as an effort, it sounds like, to pull the family together to get everybody closer.

Cory:            Yeah, I guess, too, they know people will care. Pretty big sense of hopelessness there. Not many people know where to turn.

John:            Yeah. Yeah, so that’s a lot of death that you saw even by the time you graduated high school. Have you had some thoughts of suicide yourself?

Cory:            Originally when I first came back, I did. I just didn’t know what to do anymore. Then I came to college, thought I was going to – wanted to do something honorable again. Again, big celebration and sent us off to college. And I get here, and things are going well at first. Then just the culture differences, like nobody understood me, didn’t know what to do. I was doing all right in classes, but I just kind of couldn’t fit in, didn’t feel like anybody understood me. I mean, they’re all pretty nice guys and gals. I could tell they were trying to, but just something I knew they didn’t.

And then now things are getting bad again. I’m trying to sleep at night. Yeah, just every time I go to sleep, I remember one time in Iraq we were sitting there, and they decided – well, I guess Al-Qaeda, they blew a whole street, whole city block, and it just – I mean, every building came down. And we were there trying to help, and you had kids with missing arms and missing eyes and moms with no legs and crying, screaming. We were trying help as best we can, and same time people shooting at us and just didn’t know what to do.

My friend’s crying. Like why the fuck are we here? Like what are we doing here? Like this isn’t what we – not what we’re here for. Yeah, I just remember a mom with no leg carrying her helpless child just in her arms, and the child was dead. I mean, just every time I go to sleep, I just remember that kid helpless laying there. And so I’m not sleeping much, a lot of drinking still. I guess I don’t know what to do anymore.

COMMENTARY: It’s not unusual for suicidal clients to present with a vast array of psychological pain. That can be overwhelming to the client and to the therapist. Cory has shared several layers of unresolved grief, traumatic war memories. The number of people whom he has known who have died by suicide is immense. Additionally, because of his cultural norms of stoicism, I’m wanting to address these parts of his experience, while not activating intense emotions. my strategy has been and will be to use reflection of content, to avoid reflecting back strong emotions like sadness or anger, to keep his collectivist perspective in mind, and to take notes in a way so that he and I can take a more intellectual and problem-solving approach to working with him on his experiences.

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If you made it this far, a big congratulations. Acquiring skills to work effectively with clients who are suicidal is challenging, but dealing with the emotions that come up is probably even more difficult. The purpose of this training video (when it becomes available) is to help practitioners obtain knowledge, learn skills, and refine their awareness of the inner and interpersonal dynamics associated with suicide assessment and intervention. When I have more information on the video’s availability, I’ll let you know.

Counseling and Psychotherapy Theory and Practice

Building Therapeutic Relationships: The Essence of Evidence-Based Counseling

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Hey. I’m sitting in an ACA session right now and inappropriately typing on my computer. There’s so much I could type right now . . . but self-censoring is nearly always a good thing.

Attached you’ll find the ppts for my presentation today. I hope you’re all well, and self-censoring in ways that are adaptive and prosocial. I’d write more, but self-control is advisable.

Evidence Based #174 ACA 18

 

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Parenting

What’s Happening at the 2018 American Counseling Association Conference in Atlanta?

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20150313_141701

The American Counseling Association annual world conference is coming to Atlanta next week (4/25-29) . . . and so am I.

This year, the ACA conference includes inspiring keynotes, 500+ unique sessions and up to 33.5 hours of CEs. I’m honored to be a part of this exciting learning and networking event. Here’s a link to general conference information: https://www.counseling.org/conference/atlanta-2018

As a part of the 500+ sessions, I’m involved in several events and would love to see you there. Here’s where you can catch me.

On Wednesday, April 25, I’m doing a full-day (6 hour) workshop titled, Tough Teens, Cool Counseling. There are plenty of seats left and you can get registration and other information at the ACA conference website: https://www.counseling.org/conference/atlanta-2018/sessions-events/pre-conference-learning-institutes

On Friday, April 27, from 2 to 3:30pm in Room A313, Kindle Lewis, Kim Parrow, and I will present: Building Therapeutic Relationships: The Heart of Evidence-Based Counseling

On Saturday, April 28, from 10:30 to Noon in Room A410, Sara Polanchek, Maegan Rides At The Door, Salena Beaumont Hill, and I will present: Using (Magic) Words to Influence Challenging Parents . . . With Cultural Commentary

Also on Saturday, April 28, from 1pm to 2pm, John Wiley and Sons is having an event in the Exhibit Hall to launch the publication of 3rd edition of Counseling and Psychotherapy Theories in Context and Practice. There will be coffee and cookies. Although I was tempted to select excerpts of this exciting new textbook and offer dramatic readings, instead, Rita and I will just be low key at the Wiley booth, meeting and greeting people, and answering any questions that might come up about the book or about life. Please come have a cookie with us so that we’re not standing there awkward and alone.

Last, but far more than least, on Saturday night I have the honor of receiving the Don Dinkmeyer Social Interest Award. The ACA National Awards event is from 6-7pm at the Omni Hotel at CNN Center, in the International Ballroom E & F.

Whether you attend ACA or not, I hope you’ll join the 55,000 members (and me) in working to facilitate greater mental and emotional health around the world.

Counseling and Psychotherapy Theory and Practice

Can Male Therapists Do Feminist Therapy with Male Clients? You Decide — A Feminist Case Example

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Fishing Big Davis

The 3rd edition of Counseling and Psychotherapy Theories in Context and Practice will be available very soon. Just in case you’re longing to see the cover as much as I am, there’s a link to the new edition on Amazon. Although I’m betting your longing is much smaller than my longing, here’s the link anyway: https://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1119279127/ref=dp_ob_title_bk

To celebrate this forthcoming epic publication (it’s not really epic, but some days it felt like a long poem), I’m posting a case presentation from the feminist chapter. Honestly, I don’t know who gets to decide what’s epic or what’s feminist therapy. That being the case, you can decide on both points. Or you can decide you’ve had enough of JSF for today.

Here we go.

*******

In an interesting twist, we’re featuring a case with a male therapist and male client in the feminist chapter to illustrate how working within a feminist model can work for boys and men. This case focuses on a 16-year-old male’s struggle with emotional expression. John SF is the therapist.

Josh was a White, 16-year-old heterosexual sophomore in high school. He had never met his biological father and lived in a middle-class neighborhood with his mother and three younger sisters. His mother was diagnosed with bipolar disorder. Josh’s main loves were consistent with his gender identity. They included basketball, cars, girls, and sarcasm. He very much disliked school.

Josh and I met for therapy for several years. At the beginning of one of our sessions Josh handed me a packet of photos.

“Hey, what’s this about?” I asked.

He responded with a half-mumble about a recent awards ceremony. I thought I discerned pride in that mumble. I looked through the pictures while he told me about each one. There was one in particular that he gently lifted from my hands. It was a picture of him in a line-up with five other people. He carefully pointed out that he was standing next to the Lieutenant Governor of Oregon. I teased him because there were no pictures of him and the actual governor.

“What’s the deal?” I asked. “Wouldn’t the Guv pose with you?” Josh rolled his eyes and signaled for me to move on to the next photo.

The Problem List and Problem Formulation

Unlike CBT, feminist therapy doesn’t involve collaboratively generating a concrete problem list and formulating problems as if the problems resided in the client. Instead, because problems and problem-formulation are inseparable, we can’t talk about the problems without also talking about cultural factors creating and contributing to the problems.

If client issues are discussed as problems, they’re likely discussed as situational challenges. In Josh’s case, his mother initially had brought him to therapy for anger management. Anger was consistently a regular focus in Josh’s therapy. Like many 16-year-old boys immersed in the dominant U.S. culture, Josh’s emotional life was highly constricted. He was living by Pollack’s boy code (2000) and unable or unwilling to risk feeling anything other than anger and irritation. From the feminist worldview, this wasn’t Josh’s problem; his issues around anger stemmed from him living in a culture that kept him in an emotional straitjacket.

Josh’s issues (and case formulation from a feminist perspective) looked like this:

  1. Learning to deal more effectively with sadness, grief, and anger within the context of a repressive emotional environment.
  2. Coming to an understanding that his beliefs and views of emotional expression were not in his best interest, but instead, foisted upon him by toxic cultural attitudes about how boys and men should experience and express emotion.
  3. Developing trust and confidence in himself—despite not having a father figure or a mother who could provide him and his sisters with a consistently safe and stable home environment.
  4. Learning to talk about what he really feels inside and pursue his life passions whatever they might be instead of reflexively pursuing culturally “manly” activities.
  5. Expanding Josh’s limited emotional vocabulary through consciousness-raising.

Interventions

Feminist therapists are technically eclectic; they use a wide range of interventions imbedded in an egalitarian and mutually empathic relationship:

  1. Encouraging Josh to speak freely and openly about his life experiences.
  2. Empathic listening with intermittent focusing on more tender emotions, depending on how much of this Josh was willing or able to tolerate.
  3. Therapist self-disclosure and modeling.

As Josh and I looked at photos together, I responded with interest and enthusiasm. Because interpersonal connection is a core part of therapy, I didn’t rush him to move on to our therapy agenda. Instead, I shifted back and forth between saying, “Cool” or “What’s going on there?” to making sarcastic wisecracks like “Why exactly did the government let you into the capital building?” Sarcasm was used to express interest and affection indirectly, mirroring Josh’s humor and style. After seeing most of the photos I asked, “Who’s the person standing next to you?” I could tell from his response that I had asked a good question.

“Oh, yeah, her. Her name is Sharice; her mentor was getting the same award as my mentor. I danced with her. She’s a good dancer.”

We talked about dancing and what it was like for him to feel attracted to her. We were ten minutes into therapy and both of us had completely ignored the fact that we hadn’t been able to see each other for five weeks. Finally, I decided to break the avoidance pattern. I asked “So…how are you doing with all that’s been going on?”

He looked toward me, glancing downward.

“I’m doing okay, I guess.”

Because this was a young man who had been socialized to keep his emotions tightly wrapped, I probed, but gently.

“I understand it’s been pretty wild times?”

He looked up, eyes fixed on some invisible spot on the ceiling. I recognized this strategy—a surefire way avoid crying in public. An upward gaze constricts the tear ducts; tears cannot flow.

He looked back down and said, “I’ve been busy. My mom’s been in the hospital for about a month.”

“I heard she had a pretty hard time.”

He grunted and then, in a quiet growly voice, the words, “Let-me-tell-you-about-it” seeped out from behind his teeth. Silence followed. I cautiously probed a bit more by sharing more of what I knew.

“I talked with your mom yesterday. She told me that she got pretty caught up in some housing project.” This statement lit a fire in Josh and he plunged into the story.

“You won’t believe what she did. It was so f*ing stupid. Some punk developer is gonna build three houses. Three houses at the end of our street. This is no big deal. She just f*ing freaked out. She chained herself up to a tractor to stop them from building a house. Then she called the f*ing senator and road department and I don’t know who in hell else she called. She was totally nuts. So I told her she had a choice. I told her that she could go back home or I’d call the police and have her committed. She wasn’t taking care of my sisters. She was being a shit for a mom. So I just gave her a choice.”

I nodded and said, “You must be practicing to be a parent. That’s the kind of choice parents give their kids.”

His voice grew louder: “I gave her the choice five times. Five f*ing times! She tried to buy a Mercedes and a Volvo over the phone. So I called the cops. And the woman asked ME what to do. I’m f***ing 16 years old and they f *ing ask me what to do. I didn’t know what to say. I told ‘em to come get her. They finally sent some really big cops over to take her away.”

“Then what happened?”

“My mom was still acting nuts and my sisters were crying. So I just picked them up and held them and they took her away. We sat and they cried and we snuggled a while. And then I drove us home. I don’t have my license, but I can drive. My mom is still pissed at me about that, but I don’t give a shit!”

While listening to Josh, I formed an image of him in my mind. I saw an awkward 16-year-old boy “snuggling” his sobbing sisters, as the cops take their mother away. The girls were 9 and 6 and 4 years old—the same sisters he had complained about in previous therapy sessions.

Talking with teenage boys about emotional issues is tricky. Too much empathy and they retreat. No empathy and you’re teaching the wrong lesson. Throughout Josh’s storytelling, I used sarcasm, empathy, and emotional exploration, like, “What was that like for you to gather up your sisters and take care of them?” I suspected that if I asked too much about feelings or forced him to go too deep too fast, I would lose my “coolness rating” and there would be a relationship rupture.

Much of the session focused on empathy for Josh’s anger. Josh ranted and I listened. He was immensely angry and disappointed and hurt about his mother’s behavior. But I wanted to find a way to let Josh know that it’s okay, even a positive thing, for boys and men to feel and express more tender feelings.

About halfway through our session, I asked:

“So Josh,” I said, “When was the last time you cried?”

After a short pause he spoke with extreme deliberation, “I… don’t… cry… I… just… get… pissed.”

Josh expressed this masculine emotional principle very efficiently and then offered more about his socially coerced, but internalized emotional philosophy.

“Crying doesn’t do any good. It doesn’t change anything. It’s just stupid.”

“I know, I know” I said. “The whole idea of crying sounds pretty stupid to you. It’s not like crying will change your mom and make her better.”

“Nothing will ever change her.”

I renewed my pursuit of when he last cried. He insisted that was so long ago that he couldn’t recall, but we both knew that several years ago, after an especially hard week with his mother, he had sat on my couch and sobbed himself to sleep. Instead of bringing that up, I asked him what might make him cry now. Would he cry if his girlfriend broke up with him… if he lost his cell phone… if one of his sisters got cancer… if he didn’t graduate high school? Josh fended off my questions about tears by repeating his resolve to get “pissed” about everything that might make him feel sad. But the question about one of his sister’s getting cancer stumped him. He admitted, “Yeah, I might cry about that…” while quickly adding, “…but I’d do it alone!”

I responded, “Right. Absolutely. Some things might be worth crying about… even though it wouldn’t change things… but you’d want to do the crying alone.”

We talked indirectly and intellectually about sadness and tears, trying to model that we can talk about it—once removed—and if he cried someday, it would be perfectly okay, there would be no need to feel ashamed.

Toward the end of the session, I decided to lighten things up by teasing Josh about his social insensitivity. I said, “I can’t believe that we’ve talked this whole hour and you never asked a single thing about me.”

Josh grinned. He knew therapy was all about him and not about me. He probably thought I was playing some sort of therapy game with him. He was a good sport and played along.

“Okay. So what am I supposed to ask?”

I acted offended, saying, “After all those questions I asked you, at least you should ask me when I last cried.”

“God you don’t know when to drop things. Okay. So when did you cry?”

I said, “I think it was yesterday.”

Our eyes met. He looked surprised. I continued, “Yeah. I feel sad sometimes. It can be about really hard stories I hear in here or it can be about my own life. Even though it doesn’t change anything, it can feel better to let my sadness out.”

It was time for the session to end. We both stood and I said, “We have to stop for today, but we can talk more about this or whatever you want to talk about next time.”