Tag Archives: Counseling

Counseling and Psychotherapy Theory and Practice

Attachment-Informed Psychotherapy

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In the past decade or so I’ve been fascinated over the immense growth in popularity of all things “attachment.” Don’t get me wrong, I believe attachment concepts are robust, interesting, and sometimes useful. I guess I’m not on the attachment bandwagon . . . but I’m not altogether off the bandwagon either.

Here’s an excerpt from our Counseling and Psychotherapy Theories text on Attachment-Informed Psychotherapy. I wonder, before you read this do you know the MAIN difference between attachment-informed psychotherapy and psychoanalytic psychotherapy? I ask this because mostly psychoanalytic psychotherapy is in disfavor, but attachment approaches are all the rage. Do you know the difference?

Attachment-Informed Psychotherapy

Attachment, both as a model for healthy child development and as a template for understanding human behavior is immensely popular within the United States (Cassidy & Shaver, 2008; Wallin, 2007). This is especially ironic because attachment theory’s rise to glory parallels decreasing interest in psychoanalytic models. If you were to ask a sample of mental health professionals their thoughts on attachment theory, you’d elicit primarily positive responses—despite the fact that attachment theory is a psychoanalytically oriented approach.

John Bowlby, who was raised primarily by a nanny and sent to boarding school at age seven, began writing about the importance of parent-child interactions in the 1950s. He was a psychoanalyst. Similar to other neo-Freudians, Bowlby’s thinking deviated from Freud’s. Instead of focusing on infant or child parental fantasies, Bowlby emphasized real and observable interactions between parent and child. He believed actual caretaker-infant interactions were foundational to personality formation (aka the internal working model).

In 1970, Mary Ainsworth, a student of Bowlby’s and scholar in her own right, published a study focusing on children’s attachment styles using a research paradigm called the strange situation (Ainsworth & Bell, 1970). Ainsworth brought individual mother-child (6 to 18 months) pairs into her lab and observed them in a series of seven 3-minute episodes or interactions.

1. Parent and infant spending time alone.
2. A stranger joins parent and infant.
3. The parent leaves infant and stranger alone.
4. Parent returns and stranger leaves.
5. Parent leaves; infant left completely alone.
6. Stranger returns.
7. Parent returns and stranger leaves.

During this event sequence, Ainsworth observed the infant’s:

  • Exploration behavior.
  • Behavioral reaction to being separated from parent.
  • Behavioral reaction to the stranger.
  • Behavior when reunited with parent.

Based on this experimental paradigm, Ainsworth identified three primary attachment styles. These styles included:

1. Secure attachment.
2. Anxious-resistant insecure attachment.
3. Anxious-avoidant insecure attachment.

In 1986, Ainsworth’s student and colleague Mary Main (1986, 1990), identified a fourth attachment style labeled, disorganized/disoriented attachment.

Many contemporary therapists view attachment theory in general, and Ainsworth and Main’s attachment style formulations in particular, as having powerful implications for human relationships and the therapy process (Eagle, 2003; Wallin, 2007). For example, one of the most popular approaches to couple counseling relies heavily on attachment theory principles (Johnson, 2010). In addition, attachment theory has profoundly influenced child development and parent training programs (J. Sommers-Flanagan & R. Sommers-Flanagan, 2011).

At its core, attachment theory involves an effort to understand how early child-caretaker interactions have been internalized and subsequently serve as a model for interpersonal relationships. This is, of course, the internal working model—with an emphasis on how real (and not fantasized) early relationships have become a guide or template for all later relationships. Byrd, Patterson, and Turchik (2010) describe how attachment theory can help with selecting appropriate and effective interventions:

Therapists may be better able to select effective interventions by taking the client’s attachment pattern into consideration. For instance, a client who is comfortable with closeness may be able to make good use of the therapeutic relationship to correct dysfunctions in his or her working models of self and others. On the other hand, a client who is not comfortable with closeness may find it difficult to change internal working models through the therapeutic relationship. Finally, knowing that a client is not comfortable with closeness would allow the therapist to anticipate a relatively impoverished alliance, and therefore avoid interventions such as insight oriented or object relations therapies that rely heavily on the alliance. (p. 635)

As an internal working model, attachment theory also has implications for how therapists handle within-session interpersonal process. Later in this chapter we provide an attachment-informed psychoanalytic case example (see the Treatment Planning section).

It should be emphasized that many criticisms of attachment theory exist. Some critiques have similarities to criticisms of psychoanalytic theory. Perhaps the greatest criticism is the tendency for individuals to take the Mary Ainsworth’s 21 minutes of behavioral observations with one primary caregiver and generalize it to the entire global population. In this sense, the theory is not especially multiculturally sensitive. It seems obvious that there are many divergent ways to raise children and not all cultures subscribe to the “American” overemphasis and perhaps preoccupation with the infant’s relationship with a single caregiver (usually the mother).

Although scientific critiques have sought to reign in attachment theory as it has galloped its way into pop psychology and the media (Rutter, 1995), its popularity continues to escalate and the consequences seem to magnify the importance of an overly dramatized dance of love between a child and his or her mother. In the following excerpt from A general theory of love, you can see the language is absolute and, interestingly, rather sexist—in that children are typically portrayed as male and parents as female.

One of a parent’s most important jobs is to remain in tune with her child, because she will focus the eyes he turns toward inner and outer worlds. He faithfully receives whatever deficiencies her own vision contains. A parent who is a poor resonator cannot impart clarity. Her inexactness smears his developing precision in reading the emotional world. If she does not or cannot teach him, in adult-hood he will be unable to sense the inner states of others or himself. Deprived of the limbic compass that orients a person to his internal landscape, he will slip through his life without understanding it. (Lewis, Amini, & Lannon, 2001, p. 156)

Take a moment to imagine how Karen Horney or Mary Ainsworth might respond to this overgeneralization of attachment concepts and blaming of mothers for their children’s emotional deficiencies.

John and Nora

Counseling and Psychotherapy Theory and Practice, Tough Kids Cool Counseling

A Relationally-Oriented Evidence-Based Practice Model for Mental Health Counselors

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This paper is an adapted summary and extension of an article recently published in the Journal of Mental Health Counseling (April, 2015, pp. 95-108). The original article was titled: Evidence-Based Relationship Practice: Enhancing Counselor Competence. This abbreviation and adaptation is primarily designed to summarize the content, but also to focus more directly on the implications of developing an evidence-based model especially for mental health counselors. This paper ends with an “Appendix” outlining specific parameters of an evidence-based mental health counseling model. The Appendix material isn’t in the original article. If you’re a member of the American Mental Health Counseling Association, you can find the original article here: https://amhca.site-ym.com/?JMHCv37n2

Foundations

There are two domains that serve as a foundation for all competent mental health practice. These are:

1. Ethical practice
2. Multicultural sensitivity.

Professional counselors must practice ethically. At minimum, this means abiding by the ACA (2014) and American Mental Health Counselors Association (AMHCA; 2010) ethical codes. Ponton and Duba (2009) referred to this commitment as a covenant professional counselors have with and for their clients.

Traditional theoretical perspectives must be modified or expanded to address cultural diversity (J. Sommers-Flanagan, Hays, Gallardo, Poyralzi, Sue, & Sommers-Flanagan, 2009). Clients should not be expected to adapt to their counselor’s theory; rather, counselors should adapt their theory or approach to fit clients (Gallardo, 2013). Although multicultural competence is an ethical mandate, the need to embrace multicultural awareness, knowledge, and skills is also a practical reality. [The original article lists six evidence-based ways in which mental health counselors can adapt their counseling services to be more multiculturally sensitive.]

Evidence-Based Counselor Competence

Given the nature of professional counseling and counselor identity, it seems obvious that mental health counselors should embrace a model for counseling competence and EBP that emphasizes therapeutic relationships. That is why the model I propose considers both theoretically and empirically supported relationship factors and specific interventions (procedures). . . .

The reality is that relational acts and treatment methods are so closely interwoven that in counseling sometimes it is difficult to discern which is operating at a given moment (Lambert & Ogles, 2014). Consequently, the following Relationship-Oriented Evidence-Based Practice (ROEBP) behavioral descriptions incorporate both relational and technical components. The ROEBP behavior list primarily focuses on evidence-based relationship factors, although these relational factors are nearly always teamed with technical procedures.

Evidence-Based Relationship Factors

Each mental health counselor will inevitably display therapeutic relational factors in unique ways that may be difficult for other practitioners to replicate, because anything relational or interpersonal is alive, automatically unique, and therefore resists sterile descriptive language. Nevertheless, counselors can implement the following core relational attitudes and behaviors in their own unique manner and still adhere to EBP principles.

Congruence and Genuineness

In mental health counseling, the counselor is the instrument through which treatment is provided. This is probably why Rogers’s original core condition of congruence (1957) is still central to counseling efficacy. However, because Natalie Rogers (Sommers-Flanagan, 2007) once told me that she believed very few mental health professionals in the U.S. really understand her father’s work, let me make four brief points about congruence [You can read the original article to get the details on this].

The Working Alliance

In 1979, Bordin described the working alliance as a three-dimensional and pan-theoretical therapeutic factor. The three dimensions were (a) forming an emotional bond; (b) counselor-client goal-consensus or agreement; and (c) task collaboration. Researchers have affirmed that these working alliance dimensions contribute to positive treatment outcomes (Horvath, Re, Flückiger, and Symonds, 2011). [Practical ways in which mental health counselors can apply these three dimensions in their work are described in the article.]

Unconditional Positive Regard or Radical Acceptance

Originally, Rogers (1957) described unconditional positive regard as the counselor “experiencing a warm acceptance of each aspect of the client’s experience” (p. 98). This is, of course, often impossible. Though unconditional positive regard is easy and natural when counselor and client values are aligned, the competent counselor recognizes that there will be many discrepancies, small or large, between what the counselor thinks is right and what the client thinks is right. I recall a Pakistani Muslim supervisee who reported that hearing people talk about being gay or lesbian made her feel physically nauseated. To her credit, she worked through this (over a period of two years) and was able to embrace an accepting attitude. . . .

In addition to Rogers’s work, I’ve found Marsha Linehan’s dialectical behavior therapy concept of radical acceptance (1993) very helpful. As someone who has logged many counseling hours with clients who display challenging behaviors, remembering radical acceptance helps me greet even the most extreme and disagreeable (to me) client statements with a genuine accepting response (usually something like, “Thanks so much for sharing that with me and being so honest about what you think”).

Empathic Understanding

You should already be thoroughly familiar with Rogers’s ideas about empathy and the robust empirical support for empathy as a contributor to positive counseling outcomes. However, one important caveat about empathy is that the personal feelings of counselors and ratings of their own empathy are relatively unimportant. What matters is whether and how much clients experience their counselors as empathic. This is a crucial distinction. It is all too easy for all humans—including counselors—to focus on their side of interpersonal experiences. When it comes to whether empathy is a facilitative therapy condition, it is the client’s judgment of whether the counselor was empathic that predicts positive outcomes. . . .

Rupture and Repair

Getting it wrong is a natural part of life and counseling. There will always be empathic misses, poorly timed disclosures, and intermittent disengagement. These should be viewed as inevitable problems in the working alliance. As in many other areas of life, tension in the counselor-client relationship offers both danger and opportunity.

The danger is that counselors will ignore, overlook, or be unaware of relationship tensions or ruptures, in which case clients will be more likely to drop out of counseling and outcomes will be adversely affected. But the chance to correct our missteps is an unparalleled therapeutic opportunity. It involves the powerful process of self-correction and refocusing on the client and the counselor-client relationship. . . .

Although there are many ways to repair or work through relationship rupture, the original article discusses two overarching approaches.

Managing Countertransference

Thirty years ago Steve de Shazer (1984) not only reported that “resistance” had died as a therapeutic concept, he held a funeral for it in his backyard. Similarly, some counselors and psychotherapists might like to bury the whole idea of countertransference, putting it out of sight and out of mind. However, renaming or ignoring constructs will not make them go away.

Counselors are more effective when they are aware of and deal with their own unresolved emotional and behavioral reactions (Hayes, Gelso, & Hummel, 2011). Personal counseling or psychotherapy, clinical supervision, participation in peer supervision groups—such practices can help counselors become aware of and gracefully work through their countertransference reactions.

Implementing In- and Out-of-Session Procedures

Proponents of ESTs and EBP emphasize the importance of employing specific psychological or behavioral procedures with clients. Among the procedures that have empirical support are relaxation, exposure, behavioral activation, and problem-solving (Sommers-Flanagan & Sommers-Flanagan, 2012). In addition, some procedures, such as eye movement desensitization reprocessing (EMDR), have significant empirical support even though it is not clear whether the eye movements themselves or other parts of the tightly controlled EMDR protocol are the “active” ingredients. To be consistent with an evidence-based mental health counseling model, professional counselors should implement empirically supported procedures, but should do so using a collaborative interpersonal process. . . .

Progress Monitoring

Progress monitoring (PM) is a relatively new phenomenon on the evidence-based scene. PM is robustly related to positive outcomes and relatively easy to apply (Meier, 2015). Although not covered by many professional counseling publications, all practicing counselors should integrate some form of PM into their practice.

PM simply means that, formally or informally, counselors consistently check with clients about “how things are going.” Data from empirical studies consistently show, however, that practitioners who use formal progress monitoring rating scales tend to have both more favorable outcomes and fewer negative outcomes or treatment failures (Meier, , 2015). . . .

Concluding Comments

Mental health counselors can and should integrate evidence-based approaches into their practice. Although it might be useful for counselors to seek training in ESTs, embracing and applying evidence-based relationships as a core component of counselor competency is more consistent with professional counselor identity. The purpose of making this distinction and providing the information in this article is to advocate for an alternative evidence-based identity—one that counselors can more wholeheartedly embrace.

In this article I focused on nine relational factors that are empirically linked to positive counseling outcomes. This is only a beginning. Research will continue, and for space reasons I neglected several dimensions of counselor-client relational interactions that are consistent with professional counselor identity. For example, other than a brief discussion of PM, I did not address the potential merits and problems of formal assessment. In the future I would hope for a more distinct assessment model that specifies how counselors interact with clients, emphasizing transparency and collaboration. But that discussion must wait for another day. Until then, I wish you all the best as you incorporate relationally-oriented evidence-based counseling principles into the exceptionally important services you provide.

References are included in the original article

Appendix

[This is added material]

A General Practice Model for Evidence-Based Mental Health Counseling

Different professional groups use different terminology for describing their usual and customary standards for clinical practice. In psychology “empirically-supported” is often, but not always used as a means for identifying an approach that meets scientifically-based standards. Physicians and psychiatrists establish “practice parameters” for treating specific disorders. For example, the American Academy of Child and Adolescent Psychiatry (AACAP) has a Committee on Quality Issues that has generated practice parameters for depressive disorders, obsessive-compulsive disorders, multicultural competency, and many other areas of child and adolescent psychiatric clinical practice.

Given that psychology and medicine have their own language for referring to evidence-based standards, it might be useful for professional counseling to come up with its own terminology. This would be terminology that reflects an emphasis on achieving wellness (rather than the medical model) as well as the relational emphasis consistent with counseling. In the Journal of Mental Health Counseling article I referred to this as: Relationship-Oriented Evidence-Based Practice (ROEBP). This isn’t bad, but I’m guessing someone might be able to do better at capturing counselor identity within an evidence-based practice.

Here’s a first try at outlining an ROEBP for mental health counseling. I recognize that this is mostly a rough outline, but also believe that any practice guidelines that are established for professional mental health counselors should be broad so as to include many different and unique styles that exist among individual counselors.

1. All mental health counselors embrace their professional ethical guidelines and use multicultural sensitivity and appropriate multicultural adaptations when working with individual clients. These foundational competencies and commitments must be present for a professional counselor to claim he or she is practicing evidence-based mental health counseling.

2. Mental health counseling is initiated using a collaborative informed consent process. This process should include both written informed consent (consistent with HIPAA), but also verbal interactions to help make every specific counselors approach and style explicit to prospective clients.

3. When referral information is available to mental health counselors, at least some of this information is shared directly with clients using a positive and strength-based format and interaction.

4. Mental health counselors intentionally employ empirically-supported relationship factors throughout counseling. These include, but may not be limited to:

a. Having an office-setting and interpersonal demeanor that contributes to the development of a positive emotional bond between client and counselor

b. Developing a list of mutually agreed upon problems or goals that constitute the main focus of counseling. This involves a collaborative and empathic process.

c. Working with clients on in-session tasks or procedures that are explicitly linked to the mutually agreed upon counseling problems or goals.

d. Congruence and Genuineness

e. Unconditional Positive Regard or Radical Acceptance

f. Empathic Understanding

g. Managing Ruptures and Engaging in Repair

h. Managing Countertransference

5. Recognizing that clients are sometimes drawn toward and benefit from the application of specific therapeutic procedures, mental health counselors seek permission to use these procedures with clients if they are appropriate for the remediation of a particular problem and/or for client personal growth. The procedures employed should be empirically supported. If they are not empirically-supported (e.g., procedures from energy psychology) clients should be informed that the procedure may be promising, but is not a standard and accepted counseling procedure.

6. Mental health counselors use either a formal or informal progress monitoring procedure to consistently check with clients regarding the client’s perception of counseling progress.

Feel free to email me at john.sf@mso.umt.edu with comments about this article summary and ideas about evidence-based mental health counseling practice.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

What’s the Difference between the Clinical Interview and Full-On Counseling or Psychotherapy?

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I know my obsession with all things clinical interviewing is abnormal. This means I already know that most humans on the planet will have no interest in my hashing out the details and differences between clinical interviewing and psychotherapy. So, why then do I persist on blogging about such things? Well, the answer is simple: Obsessions are thoughts and compulsions are behaviors. Therefore, obsessions and compulsions go together like beans and rice. And so, as George Bush senior might have said, “It wouldn’t be prudent to not follow my clinical interviewing obsessions with a clinical interviewing behavior or two.” Now that I think of it, I’m certain that’s exactly what GWB I would have said, had he been asked about this very important situation.

There is, of course, the other reason. I’m revising (along with Rita) our Clinical Interviewing text to put it into the 6th edition. While doing so I have intermittent inspirations to post some of the new material we’re adding here and there. I think to myself . . . “this is the 6th edition of one of the most profound and exciting textbooks of all time and so I’m sure there might be 6 people out there who are interested in reading about what we’re writing.” Then again, as most of us know from either psychological research or common sense, it’s super-easy for me to fool myself into thinking other people are interested in whatever I’m interested in.

Now, having sufficiently fooled or rationalized or intellectualized or inspired myself . . . I present you with our latest thinking on clinical interviewing vs. counseling and psychotherapy.

Clinical interviewing vs. Counseling and Psychotherapy

Students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question and although it’s tempting to answer flatly, “There’s no difference whatsoever” the question deserves a more nuanced response.

The clinical interview is a remarkably flexible and ubiquitous interpersonal process. It’s designed to simultaneously initiate a therapeutic relationship, gather assessment information, and begin therapy. As such, it’s the entry point for clients (or patients) seeking mental health treatment, case management, or any form of counseling. Depending on setting, clinician discipline, theoretical orientation, and other factors, the clinical interview is also commonly known as the intake interview, the initial interview, the psychiatric interview, the diagnostic interview, the first contact or meeting, or any one of a number of other idiosyncratic and theoretically-driven names (Sommers-Flanagan, 2016, in press).

Although it includes therapeutic dimensions, the clinical interview is viewed primarily as an assessment procedure. This is one reason why clinical interviewing is typically included within the assessment portion of course curricula in counseling, psychology, psychiatry, psychiatric nursing, and social work. However, beginning with Constance Fischer’s work on Individualized Psychological Assessment and continuing with Stephen Finn’s articulation and development of therapeutic assessment, it’s also clear that, when done well, clinical assessment is or can be simultaneously therapeutic.

To make matters more complex, every attitude, technique, and strategy described in this text are also the attitudes, techniques, and strategies used in counseling and psychotherapy. Examples (along with their theoretical orientations) range from projective questions (psychoanalytic), therapeutic questions (solution-focused therapy), unconditional positive regard (person-centered), to psychoeducation (cognitive behavior therapy). Even further, some theoretical orientations ignore or de-emphasize assessment to such an extent that the traditional initial clinical assessment interview is transformed completely into an intervention (think solution-focused or narrative). In other cases, the clinical setting or client problem require that single therapy sessions involve an entire course of counseling or psychotherapy. For example,

“. . . in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish . . . an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.” (Sommers-Flanagan et al., 2015, p. 2)

From this perspective, not only is the clinical interview always the starting point for counseling, psychotherapy, and case management, it also may be the end-point. This is partly because many clients stop treatment after only one therapy session.

There may be other situations where an ordinary therapy session (if there is such a thing) can suddenly transform into a clinical assessment interview. The most common example of this involves suicide assessment interviewing (see Chapter 10). If and when clients begin talking about suicide ideation or exhibiting other suicide risk factors, the usual and customary standard of practice for all mental health and healthcare professionals is to smoothly shift the clinical focus from whatever was happening to a state-of-the-art suicide assessment.

All this leads us to the stunning conclusion: Everything that happens in a full course of counseling or psychotherapy may also occur within the context of a single clinical interview—and vice versa. Although it’s usually the starting point of counseling and psychotherapy, parts of a traditional clinical interview also occur during counseling and psychotherapy, regardless of theoretical orientation. The entire range of attitudes, techniques, and strategies you learn from this text constitute the foundation of skills you’ll need for conducting more advanced and theoretically specific counseling or psychotherapy.

R and J in Field

Boys and Men, Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

Cleavage, Revisited

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It’s revision time for the Clinical Interviewing textbook (the 6th edition is coming). Revision time also means revisiting time. About three years ago I posted a new proposed section for the 5th edition cleverly titled, “Straight Talk about Cleavage.”

This time around I’m posting our slightly revised version of that section. What’s new is that I’m explicitly asking and hoping for your comments and feedback. Please note that this makes me nervous, but we (Rita and I) hope your comments and feedback will help us provide more perspective and depth to our discussion. We don’t want to come across as old fogeys or rabid feminists. Instead, we want to be reasonable, thoughtful, and balanced . . . and so we’re turning to YOU.

The section is below. You can post comments directly here at Word Press for all to see or email me privately at john.sf@mso.umt.edu.

Straight Talk about Cleavage

Although we don’t have any solid scientific data upon which to base this statement, our best guess is that most of the time most people on the planet don’t engage in open conversations about cleavage. Our goal in this section is to break that norm and to encourage you to break it along with us. To start, we should confess that the whole idea of us bringing up this topic (in writing or in person) and saying something like, “Okay, we need to have a serious talk about cleavage” makes us feel terribly old. But we also hope this choice might reflect the wisdom and perspective that comes with aging.

In recent years we’ve noticed a greater tendency for female counseling and psychology students (especially younger females) to dress in ways that might be viewed as somewhat provocative. This includes, but is not limited to, low necklines that show considerable cleavage. Among other issues, cleavage and clothing were discussed in a series of postings on the Counselor Education and Supervision (CES) listserv back in 2012. The CES discussion inspired many of the following statements that follow. Please read these bulleted statements and consider discussing them as an educational activity.

  • Female (and male) students have the right to express themselves via how they dress.
  • Commenting on how women dress and making specific recommendations may be viewed as sexist or inappropriately limiting.
  • It’s true that women should be able to dress any way they want.
  • It’s also true that agencies and institutions have some rights to establish dress codes regarding how their paid employees and volunteers dress.
  • Despite egalitarian and feminist efforts to free women from the shackles of a patriarchal society, how women dress is still interpreted as having certain socially constructed messages that often, but not always, pertain to sex and sexuality.
  • Although efforts to change socially constructed ideas about women dressing “sexy” can include activities like campus “slut-walks,” a counseling or psychotherapy session is probably not the appropriate venue for initiating a discourse on social and feminist change.
  • For better or worse, it’s a fact that both middle-school males and middle-aged men (and many “populations” in between) are likely to be distracted—and their ability to profit from a counseling experience may be compromised—if they have a close up view of their therapist’s breasts.
  • At the very least, we think excessive cleavage (please don’t ask us to define this phrase) is less likely to contribute to positive therapy outcomes and more likely to stimulate sexual fantasies—which we believe is probably contrary to the goals of most therapists.
  • It may be useful to have young women (and men) watch themselves on video from the viewpoint of a client (of either sex) that might feel attracted to them and then discuss how to manage sexual attraction that might occur during therapy.

Obviously, we don’t have perfect or absolute answers to the question of cleavage during a clinical interview. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend you take time to think about this dimension of professional attire and hope you’ll openly discuss cleavage and related issues with fellow students, colleagues, and supervisors.

Clinical Interviewing

Opportunities for Graduate Students and Professors as We Revise Our Clinical Interviewing Textbook

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Revising textbooks is a joy and a burden. When I’m first forced to face the revision process, I feel unfairly burdened. I think things like, “I thought we wrote a perfect book that would last forever. How could anyone think it needs revision?” To say that I lack the necessary enthusiasm is an understatement. I lack any enthusiasm.

However, once I dive back into the text, it’s like visiting an old friend. And in this case, the good news is that it’s like visiting an old friend whom I like very much.

Rita and I started working on the first edition of Clinical Interviewing way back in 1990. Yep. It’s a very old friend.

During the next 6-8 months, we’ll be working on the 6th edition revision. If you’re a graduate student or faculty in Counselor Education, Psychology, or Social Work, we’re looking for your help. But, as before, we really only want your help if it will be meaningful to you. If you think that might be the case, read on:

You’re invited to help in one of four ways:

1. You can choose one or more of the chapters from the fifth edition, read it (them), and offer feedback and advice on changes you think would improve the text. We can take up to three reviewers for each chapter, but more than that will overwhelm us.

2. You can provide us with feedback and recommendations for DVD content that will help in the teaching and learning of basic and advanced counseling and interviewing assessment skills. This is very important because having excellent video content facilitates learning and is one of our big goals.

3. You can provide expert analysis of specific literature related to basic counseling skills and/or advanced interviewing assessment strategies. For example, if you’re on the cutting edge of administering mental status exams (or want to be), we can work together to read and select new literature that will help us update that chapter.

4. You can develop and write up specific classroom activities that help students learn basic and more advanced interviewing skills. If your contribution in this area is original, we’ll work with you to organize your learning activity so that it can be included as a short publication in our electronic instructor’s manual.

5. If you’re an expert in a particular area and want to send us citations of your published work, we’ll review your work and consider including those citations in the 6th edition, as appropriate.

If any of these opportunities sound good to you, or, if you have other ideas, questions, or comments about our revision process, please email me directly at: john.sf@mso.umt.edu.

Thanks for considering these opportunities to contribute to the Clinical Interviewing 6th edition!

Sincerely yours,

John SF

P.S.: In case you don’t know much about this text and the accompanying DVD, here’s what a couple reviewers said:

“A superb synthesis and presentation of the key concepts any beginning student absolutely needs to know about clinical interviewing. John and Rita Sommers-Flanagan make an eloquent case that connecting with the client on a human level is the superordinate task, without which little else of value can be achieved. Replete with relevant clinical examples, helpful how-to hints, as well as pearls of clinical wisdom, this comprehensive yet accessible text is highly recommended.”—Victor Yalom, Ph.D., Founder and CEO, Psychotherapy.net

About the DVD:
“Indispensable interviewing skills imparted by two master teachers in an engaging, multimedia presentation. Following the maxim of ‘show and tell,’ the Sommers-Flanagans provide evidence-based, culture-sensitive relational skills tailored to individual clients. An instructional gem!”
— John C. Norcross, PhD, ABPP, Distinguished Professor of Psychology, University of Scranton; Editor, Psychotherapy Relationships That Work

Personal Reflections, Writing

Writing about Writing . . . Feedback Please?

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Over the past several days I’ve been inspired to pursue a new project that focuses on writing about professional writing. This is the sort of thing that happens to me when I’m facing a big list of imposing writing projects . . . I decide to add one more.

But the good news is that I’m having fun and producing lots of words on this topic. My latest method for generating words is to go for a long walk with my cell phone. Then, I dictate email messages to myself through my cell phone and send them. Pretty cool. Over the past two days I’ve “written” almost 8,000 words.

There are some problems with this system, however. In particular, if there’s any wind, or if I don’t enunciate perfectly, my phone is inclined to misquote me. The result: In the moment I feel exceptionally articulate and then I when I get home and read the emails I’ve sent myself, I sound somewhat less articulate. Here’s an example:

1 thing keep in mind is: your trickster is not my sister. What is means is that are in your obstacles 4 demons are unique to us as individuals. You wear the standard prescription for all riders. Beware the single strategy you overcome writers block. He wear even if we say it, love 1 message to manage your picture.

You can imagine my disappointment at receiving this message from myself, I’m sure. If that preceding paragraph wasn’t absolutely hilarious, I might be furious at having lost whatever profound message I was trying to communicate with myself. But I have to say that reading these emails from myself makes for excellent entertainment.

This reminds me of a dream I had back in grad school. It was amazingly profound . . . but I’ll skip that and get to the point of asking you for feedback.

If you’re a current or recent graduate student, please send me your answer to one or more of the following questions:

1. What emotions and thoughts do you experience when you turn in a paper to a professor (or, better yet, a thesis or dissertation committee)?

2. When you get lots of “constructive feedback” what thoughts and feelings do you experience? This might involve you receiving a paper back with a low grade and/or lots of “red ink.” Can you share an example of what you think or feel in response to that situation?

3. When you get positive feedback, what thoughts or feelings does that trigger? Can you share an example?

4. After you’ve gotten negative or constructive feedback, how do you find the strength or courage to send in another draft or turn in the next assignment?

If you’re currently a professor somewhere, consider answering one or more of the following:

1. What thoughts or feelings do you have to deal with to get yourself to write something?

2. How do you react to or deal with rejection? For example, if you have a manuscript or proposal rejected, what do you say, do, think, or feel? What do you do to “bounce back” from rejections of your written work?

3. How do you react to success? For example, when you have a paper accepted or get positive feedback, how does that affect you?

4. What helps you write well . . . or in what situations are you likely to write efficiently.

Thanks for thinking about this with me. I appreciate it. And I’ll even appreciate it more if you send me an email answering some of the preceding questions. Send it to: john.sf@mso.umt.edu

And . . . I’m confident that whatever you send me will arrive in better shape than the emails I’ve been sending myself.

2014-06-03_15-45-11_474

Clinical Interviewing

Nice Review

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Victor Yalom of Psychotherapy.net recently emailed us a copy of a review of our Clinical Interviewing DVD. This is a wonderful review from someone we’ve never met . . . but we think we’d like him. He’s a professor at Western Illinois University.
Here’s an abstract of the review.
Interviewing with humanity intact.
By Knight, Tracy A.
PsycCRITIQUES, Vol 60(9), 2015, No Pagination Specified.
Abstract
Reviews the video, Clinical Interviewing: Intake, Assessment & Therapeutic Alliance by John Sommers-Flanagan and Rita Sommers-Flanagan (2014). This video blends the procedural with the human in a way that will enhance and deepen the training of mental health professionals. Beyond describing the most valuable guidelines of clinical interviewing, John and Rita Sommers-Flanagan provide multiple illustrative interviews with clearly nonscripted participants. Most importantly, the Sommers-Flanagans discuss both the information as well as the interviews, displaying both their depth of knowledge and perhaps the most important attributes of gifted clinicians: humility and curiosity. They not only provide a map, therefore, but also fully display and describe the landscape that interviewers and their clients traverse. The DVD includes seven distinct areas of focus, each one building on the previous. Initially, the authors succinctly describe basic listening skills, including both nondirective and directive approaches. Their definitions are clear and evocative, and during the sample interviews, the distinct attributes of the therapist’s actions are listed for viewers. This sets the stage for the authors’ subsequent discussion, during which they explore the dynamics of the sample interview and lucidly discuss important human factors. The reviewer concludes this video offers both knowledge and wisdom, providing students and trainees with an approach to clinical interviewing that makes the process more efficient, while always respecting the beating heart of humanity that rests within it. (PsycINFO Database Record (c) 2015 APA, all rights reserved)
Personal Reflections, Writing

My Adams State University Chi Sigma Iota Initiation Speech

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It’s an honor to be here on this excellent almost-spring-day in Alamosa, Colorado. Thanks to Jazmin, Chris, and Lori for inviting me here and arranging this visit. I’m so touched about this that I wrote a song especially for this event. And so you’ve got that to look forward to.

When it comes to giving speeches and workshops, one of my former professors used to say this: If you ask me to give a 15 minute talk, I’ll need all day to prepare; if you ask me to talk for a couple hours, I’ll likely need a couple hours of prep. But if you want me to talk all day . . . I’m ready.

This is why I have some verbatim notes here. Tomorrow I’ll be talking all day and therefore be way more spontaneous. Today, I need a guide to keep me focused.

The first thing I’d like to report is that the profession and discipline of Counselor Education is doing well . . . and maybe even booming. Just last night at the University of Montana we held our live group admissions interview for our CACREP-accredited Clinical Mental Health and School Counseling M.A. Programs. We have a total of 18-20 openings for these degrees and 71 applicants. About 45 applicants showed up for a 2 ½ hour group interview. After the interview, late into the night, we were discussing the applicants and one of our current students who was helping with the process exclaimed, “Thanks for letting me be a part of this. This was like Fantasy Football in February.” We took that as a compliment.

This is why I LOVE being a Counselor Educator. I don’t love it for the Listserv, or the ACA convention, or the status and prestige of being a Counselor Educator and teaching at the University of Montana. I love it because every year I get to spend most of my time teaching the kindest and most respectful graduate students on the planet; students who are deeply committed to helping others and to making the world just a little bit better place for individuals, couples, families, groups, schools, and communities. I have the honor of teaching these great people and maybe partly because we teach them how to have awesome listening skills, when I teach, they actually look like they’re listening to me. This is the best job ever.

And so thanks for letting ME be a part of THIS Excellent Day and CSI Induction Ceremony. It’s definitely better than fantasy football in February.

What I hope is that this is not just an initiation ceremony . . . it should also be a celebration . . . which brings up an important question: “How shall we celebrate?”

Well, of course, there should be dancing . . . and singing . . . and maybe some slam poetry . . . and of course, high fives all around, and arms raised in the air, and clapping and cheering (woo hoo) and toasting and smiling and laughing and eating desserts. Let’s do it all!

Counseling is a profession and identity that comes from the people. From way back in 1909, with Frank Parsons publishing “Choosing a Vocation” (with Pauline Agassiz Shaw’s unwavering financial and emotional support), it had become clear that modern citizens from the early 20th Century could benefit from assistance in making important decisions.

Think about that. Where do we learn to make decisions? Not just decisions about vocation and career, but other important life decisions? Did your parents explicitly teach you? Did you take a “Decision-Making” course in high school or college? Did you enroll in a life decision-making workshop? Probably not. Sometimes I think it’s mostly only in graduate school where Counselor Education students get taught how to make decisions and how to help people make important decisions.

This is still a big part of what we, as counselors, do. We help people make everyday life decisions. We help them sort through the thoughts, feelings, impulses, and social and cultural forces that make decision-making so challenging. And we help them make bigger decisions too.

Counseling is a profession with roots back in the early 1900s with Frank and Pauline, but professional counseling is a much more recent development.

Not long before Thomas Sweeney of Ohio University founded CSI in 1983, it was becoming apparent that Psychiatry, Psychology, and Social Work weren’t adequately serving the needs of all the people. In the 1960s and 70s, Psychiatry was mostly taking the BIG PHARMA road, Social Work mostly linked hands with Medical professionals, and Psychology mostly decided to embrace Ph.D.-only training, a sort of scientific fundamentalism, and the pursuit of becoming mini-physicians.

IMHO, this was a mass exodus from the needs of most people. Helping became much more about the medical model – assessment, diagnosis, and treatment – and less about helping people achieve what most of us really want in our daily lives, good health and positive wellness.

So there was something big missing. People wanted to work with professional practitioners who were empathic, kind, compassionate, and positive, and interested in helping them feel WELL, instead of just helping them not feel sick. This is the breech into which professional counseling stepped. And this is probably why, in a study conducted in the Psychology Department at the University of Montana in 1991, it was reported that consumers rated Counselors as warmer, kinder, more genuine, and more desirable to see than Psychiatrists or Psychologists.

At the University of Montana we have an MSW, a Clinical Psychology, and our Counselor Education graduate programs. Not surprisingly, we have a bit of a friendly competition for graduate students. Don’t get me wrong, I love my colleagues in Psychology and Social Work and I think they do a fantastic job educating their students; I just think their professional disciplines have gotten drawn a bit too far over into the medical model. Consequently, when prospective students ask me what program they should choose, I find it very easy to say, “If you want to learn how to do, I mean, really how to do individual, couple, family, and group counseling, then you should join us in the Department of Counselor Education.” Even the graduate students in these respective programs recognize that Counselor Education students learn these skills faster than other disciplines . . . principally because that’s what we focus on.

This brings me to some concerns for the future.

There will always be medical creep, pharmaceutical creep, and insurance company creep. The medical model is strong and compelling. We have to watch out for that. For example, right now we’re right in the middle of a Neuroscience party that’s dominating popular discourse. This reminds me of a Psychiatrist with whom I worked at a Psychiatric Hospital back in 1981. He said it wouldn’t be long until we were all taking drugs to manage and moderate our emotions and behaviors. Well, mostly he was wrong.

Now we have “brain-based” this and “brain science” that and to be “in the dominant cultural discourse club” we have to put “neuro” in front of every other word or sentence.

But there are some surprising ways in which the medical model and neuroscience don’t provide much guidance or truth.

There’s really no such thing as a chemical imbalance. If you speak Spanish and I don’t, then our unique brains have to be different. The chemical imbalance as an explanation for mental health problems has no particular scientific support.

In addition, the track record of psychiatric medications curing illness is rather abysmal. I’m not saying that medications never work, I’m just saying they work less well than most of the public has been led to believe.

And the majority of the quantitative research published in psychology journals is, to borrow Carl Rogers’s words from 1957, “for the most part, a colossal waste of time.”

My point here is: Let’s be damn good professional counselors, and not try to be like those other professional disciplines. They have their niche; they’re needed in some ways for some things. But let’s stick with what we’re doing well.

As I’m sure you all know, because I don’t have a portable MRI or PET scanner in my office—which wouldn’t allow me to really “see” what’s happening in someone’s brain anyway—there’s really only one good method for me to know what’s going on in my client or student’s brain.

The best way to do this is to sit with the person and listen well and develop a trusting relationship and ask things like:

• What are you thinking right now?
• What do you want?
• What emotions are coming up for you?
• What feelings and sensations do you have in your body?

Being with people in positive therapeutic relationship and sometimes asking no questions at all, is the best brain scanner we’ve got.

And here are a few more important truths:

1. A pill is not a skill
2. There’s no better medicine than a healthy and caring relationship, and
3. The profession that is currently doing the best at focusing on skills and relationships is Counselor Education!

As the EMDR therapists would say, “Let’s go with that.”

Before ending, I’d like to tell one short story; then we can officially start celebrating.

Meeting Jesus at the Portland VA Story: What this psychotic patient wanted and what he responded to was what most of us want and respond to . . . to be listened to . . . and to be treated with respect and as an individual, not as a psychiatric label.

Now let’s begin our official celebration with a song that I wrote especially for this auspicious occasion. Ready? I’ll sing it through first and then you can all stand if you like and join me:

Oh, I wish I were a counselor-in-training, counselor-in-training . . .
Oh, I wish I were a counselor-in-training, counselor-in-training . . .
I think it’d be rather swell
To help everyone be well
Oh, I wish I were a counselor-in-training, counselor-in-training.”

Everybody now . . .

Thanks for listening and my BIG congratulations to all of the initiates and the faculty here at Adams State University.

Parenting

How to Talk so Parents will Listen: Strategies for Influencing Parents

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Last June I had a chance to go to Chicago to be filmed doing three professional THERAPY TALKS. It was a challenging situation; just me and a camera and a few production folks. One of the TALK topics focused on how to work effectively with parents. As it turns out, this video and others I’ve done with Microtraining are now available at their website: https://www.academicvideostore.com/publishers/microtraining (you have to search for Sommers-Flanagan).

Here’s the text, more or less, from the “How to Talk so Parents will Listen” TALK.

When I talk with large groups about parenting, I like to begin with a survey. I ask: “How many of you ARE parents?” Of course, nearly everyone raises his or her hand. Then I ask a follow up: “How many of you WERE children.” At this question some participants laugh and a few raise their hands and others joke that they’re still immature.

This reason I start with this survey is because if you’re a parent, you know that being a parent is an amazing and gratifying challenge. You also know that it’s 24-7; and you know it doesn’t end when your child turns 18. You’re a parent for life. And if you WERE a child, and all of you were, then you know how important it is to have a parent or caretaker who makes it perfectly clear that YOU ARE LOVED. But there’s more. If you were a child, then you also know how important it is to have a parent who not only loves you, but who is skillful . . . a parent who is dedicated to being the best parent possible.

Plain and simple: PARENTS NEED SKILLS FOR DEALING WITH THEIR CHILDREN IN THE 21ST CENTURY. And learning to be a better parent never stops.

Once upon a time I had a mom come consult with me about her five year old son. She said: “I have a strong-willed son.” My response was to acknowledge that lots of parents have strong-willed children. She said, “No, no, you don’t get it. I have a very strong-willed son, let me tell you about it. Just the other night, I asked him to go upstairs and clean his room and he put his hands on his hips and said, “NO.” So I said in response, “Yeah, yeah. He sounds very strong willed.” And she said, “Wait. There’s more. I asked him to clean his room a second time and he glared and me, and said “NO. YOU WANT A PIECE OF ME?” Then she told me the real problem. The problem was that, in fact, she did want a piece of him at that particular point in time and so she grabbed him and hauled him up the stairs in a way that was inconsistent with the kind of parent she wanted to be.

This is one of the mysteries of parenting. How can you get so angry at a small child whom you love more than anything else in the world?

Parents are a unique population and deserve an approach to counseling that’s designed to address their particular needs. In this talk I’ll mostly be using stories to talk about:

a. what parents want for their children
b. what parents need in counseling
c. and how professionals can be effective helpers.

Most parents want some version of the same thing: To raise healthy and happy children who are relatively well-adjusted. But what do parents need in counseling. WHAT WILL HELP THEM GET WHAT THEY WANT?

First, parents need empathic listening. They need this big time. Our American culture puts lots of social pressure on parents . . . It’s implied that parenting should be easy and all parents should want to spend 24-7 with their child in an altered state of parental bliss. But this isn’t reality and so we need empathy for the general scrutiny parents feel in the grocery store, at church, on the playground, and everywhere else.

But they also need listening and specific empathy: like in the situation where the mom wanted to tell me about her 5-year-old son. She had specific information to share and it was really important for me to take time to listen to her unique story about her son who, unfortunately, may have seen too many Clint Eastwood movies.

Parents come to counseling or parent education feeling simultaneously insecure and indignant. They feel insecure because of the scrutiny they feel from their parents and in-laws and society, but they also feel indignant over the possibility that anyone might have the audacity to tell them how to parent their children. As professionals, we need to be ready to handle both sides of this complex equation.
Another thing parents have taught me over the years is to never start a parenting session by sharing educational information. You should always wait to offer educational advice, even when parents ask you directly for it. When they do ask, let them know that your ideas will be more helpful later once you get to know what’s happening in their family.

This leads us to the second crucial part of what parents need in counseling. They need collaboration. We can’t be experts who tell parents what to do, instead we have to recognize that parents are the experts in the room. They’re the experts on their children, on their family dynamics, and on themselves. If we don’t engage and collaborate with parents, very little of what we offer has any chance of being helpful.

Parents also need validation to counter their possible insecurity. We call this radical acceptance or validation and it involves explicitly and specifically giving parents positive feedback. We do this by affirming, “You sure seem to know your daughter well.” And by saying, “When I listen to how committed you are to helping your son be successful in life, I can’t help but think that he’s lucky to have you as a parent.”

And so we begin with empathic listening and we move to collaboration and we make sure that we offer radical acceptance or validation and we do all this so we can get to the main point: providing parents with specific parenting tips or guidance.
And there are literally TONS of specific parenting tips that professionals can offer parents. Most of the good ones include four basic principles:

First, getting a new attitude – because developing parenting skills requires a courageous attitude to try things out.

The second one involves making a new and improved plan. Because a courageous attitude combined with a poor plan won’t get you much.

Third is to get support when you need it. Parenting in isolation is almost always a bad idea.

Fourth, underlying all tips there should be the foundation of being consistently loving.

I’d like to tell two parenting stories to illustrate all of the preceding ideas.

This first story is about a parenting struggle I had. I share it for two reasons: One is that it’s a great example of the need for parents to make a new plan to handle an old problem. And two, often it’s good to self-disclose—but not too much—when working with parents.
When my youngest child was 5-years-old, she ALSO was a strong-willed child. I vividly recall one particular ugly scene on the porch. It was time for us to leave the house. But we lived in Montana and there was snow and my daughter needed to put her boots on. Funny thing, she was on a different schedule than I was. This created tension and anger in me. And so I got down into her face and I yelled GET YOUR BOOTS ON! And her eyes got big and she did. Later that evening I was talking with my wife and she saw the scene and she said to me, “I know John, that’s not the kind of parent you want to be.” And even though it’s not easy to take feedback from our romantic partners, she was right and so obviously so, that I had no argument” which led me to tell her, “I’m not going to yell at our daughter any more. I am, instead going to whisper, because I learned in a parenting book, that sometimes when you’re angry it’s more effective to whisper than it is to yell. That was my new plan. Of course, like new plans everywhere, it needed tweaking. But it didn’t take long for me to have an opportunity to test it because if there’s anything on the planet that’s predictable, it’s that we’ll all soon have another chance to manage our anger toward our children more constructively.

It was the next day or week and my daughter did not get her boots on and she was not on the same schedule as me and I got down in her face, once again, but I remembered the plan to whisper and I did my best to transform my anger from the historical yell to the contemporary whisper and what happened was that what came out was sort of like the exorcist and I said to my daughter: “GET YOUR BOOTS ON!”

Now. I wasn’t especially proud of that, but she got her boots on.

It was the beginning of a big change for me because I learned I could play the exorcist instead of yelling; then I learned to growl and then I learned to count to three and then I learned a cool technique called Grandma’s rule where you use the formula, WHEN YOU, THEN YOU to set a limit and build in a positive outcome. Like . . . “Honey, when you get your boots on, then you can have your cell phone back.” Very cool.

What I learned from this experience is that I could be more than a one-trick parenting pony. I became the kind of parent who, although far from perfect, was able to set limits that were in my daughter’s best interest.

And what I like the best about this particular story is that daughter is now 26 years-old and she still says the same thing she used to say to me when she was 15 . . . that is, “Dad, one thing I really love about you is you never yell.” What’s cool is that I did yell, but I worked on it, I made a new plan, and now she doesn’t even remember the yelling.

I’d like to finish with one last story about how much parents need people like you to have empathy, collaborate, validate, and offer concrete parenting ideas.

I was working with a 15-year-old boy. His mom was bringing him to counseling because he and his dad weren’t speaking anymore. I hadn’t met the dad, but one day, when I went to the boy’s IEP meeting at school the dad was there. I saw this as a chance to make a connection and get him to come to counseling.

I did a little chit-chatting and sat next to him in the group meeting. Then, at one point, I asked the boy a question: “If you got an A on a test, who would you show first?” He answered, “I’d show my dad, my mom, and my special ed teacher.” This inspired me to turn to his dad and say, “It’s obvious that you’re very important to your son and so I’d like to invite you to come join him and me in counseling.” Dad gave me a glare and pushed my shoulder and began a 2-minute rant about how the school had failed his son. Everyone was stunned and then he turned back to me and said, “I’ll come to counseling. I been to counseling before and I can do it again.”

At that point I wondered if I could take back my offer.

The day the dad drove to counseling he and his son weren’t speaking, so I met with them separately. The son was clear that he would never speak to the dad again, but the dad was open. When I asked if I could offer him some ideas, he said, “Well I tried MY best and that dog don’t hunt, so I can try something else.” I was wishing for subtitles.

I told the dad I wanted him to keep his high standards for his son, but to add three things. First, I asked, do you love your son? The dad said “Yes” and so I told him, “Okay then. I want you to tell him ‘I love you’ every day.” He said, “Usually I leave that to the wife, but I can do that.” Second, I said, “Everyday, I want you to touch your son in a kind and loving way.” He asked, “You mean like give him a hug?” I said, “that would be great” and he responded, “Usually I leave that to the wife too, but I’ll give it a shot.” Third, I said, “Once a week, you should do something fun with your son, but it has to be something that he thinks is fun.” He said back: “That’s no problem. We both like to go four-wheeling, so we’ll do that.”

And they left my office for an hour-long of what I imagine was a silent trip home.

The next afternoon, I got a call from the mom. She was ecstatic. She said, “I don’t know what you did or what you said, but they’re talking again.” And then she added, “This morning, when they were in the kitchen, I was in the other room and I thought I heard them hug and when I saw my son walking down the driveway to head to school, there were tears running down his cheeks.”
This was obviously a mom who was listening and watching very closely.

Things got much better for the 15-year-old after that. He didn’t get straight As, but he stopped getting straight Fs. And I learned two things: First, I learned just how much that boy needed to get reconnected with his father. And second, I learned that sometimes, no matter how gruff parents may seem, what they need is some clear and straightforward advice about how to reconnect with their son or daughter.

My final thoughts about this topic are very simple. I hope you’re inspired enough to acquire the knowledge and skills it takes to work effectively with parents. I know their children will deeply appreciate it.

Thanks for listening.

John and Nora

Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More information about how to work through resistance is in our Tough Kids, Cool Counseling book, which happens to have five 5-star ratings on Amazon. Check it out: