Tag Archives: Counseling

Therapy with Adolescents, Tough Kids Cool Counseling

Teaching Teens Better Strategies for Getting What they Want

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On Thursday of this week I’ll be at the Hilton Garden Inn in Missoula doing a day-long workshop on how to work effectively with challenging youth and challenging parents. Of course, the first point to make about this is that this entire concept is flawed; it’s flawed because it’s not fair to call youth and parents “challenging” when, in fact, for them, the whole idea of sitting down and talking with a counselor is challenging. It would be equally reasonable to hold a workshop for parents and youth titled, “Working with Challenging Counselors.”

One of the approaches featured during the workshop will be to engage teenagers in using better (healthier and more legal) strategies for getting what they want. Rita and I wrote about this approach in our book, Tough Kids, Cool Counseling. . . and so here’s an excerpt that describes the approach and provides a case example:

INTERPERSONAL CHANGE STRATEGIES

The following techniques focus more specifically on interpersonal behavior patterns.

Teaching “Strategic Skills” to Adolescents
Weiner (1992) described many delinquent or “psychopathic” adolescents as inherently understanding the importance of using strategies to obtain their desired goals (p. 338). Despite this general understanding, disruptive, behavior-disordered adolescents frequently utilize ineffective interpersonal strategies and thereby obtain outcomes opposite to what they desire. For example, increased freedom is commonly identified by adolescents as one of their primary therapy goals. However, attention-deficit and disruptive, behavior-disordered adolescents consistently engage in behaviors that eventually restrict their personal freedom (e.g., curfew violation, disrespect toward parents, illegal behavior). The “strategic skills” intervention is designed to help adolescents understand how their own behavior contributes to their inability to attain personal goals (e.g., perhaps by producing increased limits and restrictions).

The therapist must provide two relationship-based explanations to implement the strategic skills procedure. First, the therapist must directly inform them of a willingness and commitment to assist them in personal goal attainment. For example:

It sounds like you want more freedom in your life. I imagine it’s a drag being 15 and still having all the restrictions you have. I want you to know that I’m willing to work very hard to help you have more freedom. We just have to put our heads together and think of some ways you can get more freedom.

The purpose of this statement is to reduce resistance and distrust. Many, if not most, adolescents expect therapists to side with their parents, teachers, or authority figures. The process of valuing the adolescent’s pursuit of freedom can surprise the adolescent and thereby reduce resistance.

Second, therapists must set clear limits on the type or quality of behaviors they are willing to support and promote. This is because adolescents may try to manipulate therapists into supporting illegal or self-destructive behavior patterns (Weiner, 1992; Wells & Forehand, 1985).

I need to tell you something about what I am willing to help you accomplish. I’ll help you figure out behaviors that are legal and constructive and help you get more freedom. In other words, I won’t support illegal and self-destructive behaviors because in the end, they won’t get you what you want. And there may be times when you and I disagree on what is legal and constructive; we’ll need to talk about those disagreements when and if they arise.

If adolescents respond positively to their therapists’ offer of support and assistance, the door is open to providing feedback about how to engage in freedom-promoting behaviors. Therapists can then tell their clients: “Okay, let’s talk about strategies for how you can get more of what you want out of life.” Subsequent discussions might include the following problem areas that frequently contribute to adolescents’ restrictions: staying out of legal trouble, developing respect and trust in the adolescents’ relationships with parents and authority figures, and analyzing and modifying inaccurate social cognitions. Essentially, therapists have facilitated client motivation and cooperation and can move on to analyzing faulty cognitions, modeling and role-playing strategies, and other effective psycho-therapeutic interventions.

Case example. A 12-year-old boy entered the consulting room in conflict with his father over how many pages he was supposed to read for a specific homework assignment given to him by a teacher whom he “hated.” The boy was disagreeable and nasty in response to his father’s comments; direct discussion of issues while both father and son were present was initially ineffective. Therefore, the father was dismissed. After using distraction strategies and a mood-changing technique (See Chapter 3), the boy was able to focus in a more productive manner on the conflict he was having with his father. The boy indicated that his father was partially correct in his claims about the reading assignment, but that the boy’s “hate” for this particular teacher made him want to resist the assignment.
The individual discussion between the boy and his therapist focused on (a) how the boy’s dislike for the teacher produced a “bad mood,” which subsequently produced his resistance to the assign-ment, (b) how the boy’s bad mood and resistance to the assignment had produced disagreeable behavior toward his dad, and (c) how the boy’s bad mood, resistance to the assignment, and disagreeable behavior had produced a bad mood and disagreeable behavior within the father (who was now resisting the boy’s request that the assignment be modified). Consequently, after the boy’s mood was modified, the boy and therapist were able to brainstorm strategies for helping the father change his mood and become more receptive to the son’s request. With assistance, the boy chose to tell the father “You were right about the assignment . . . “ when his father returned to the room. This “improved” interpersonal strategy (which had been role-played prior to father’s return) had an extremely positive effect on the father. Additionally, the boy was able to introduce a compromise (“I’ll do the assignment if my dad will listen to me without disagreeing when I bitch about how unfair and stupid this teacher is”). In response to his son’s admission “Dad, you’re right,” the father stated (with jaw open): “I don’t know what happened in here when I was gone, but I’ve never seen Donnie change his attitude so quickly.” Donnie and his father successfully negotiated the suggested compromise, and before Donnie left, the therapist pointed out (by whispering to the boy) how quickly he had been able to get his father’s mood to change in a positive direction.

In this case scenario, the therapist helped to modify the son and father’s usual reciprocal negative interactions in a manner similar to one-person family therapy advocated by Szapocznik et al. (1990).

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Boys and Men, Parenting, Personal Reflections, Therapy with Adolescents, Tough Kids Cool Counseling

Entering the Danger Zone: Why Counselors (and Psychologists) Need to Find the Courage to Talk with Boys about Sex and Pornography

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This article was published in the Reader Viewpoint section of Counseling Today magazine this week. If you get the magazine, you’ll find it on page 52. If not, because it’s not available online, I’m posting the article (with minor modifications) in-full right here. To check out the Counseling Today magazine, click here: http://ct.counseling.org/

Here’s the article:

Reader Viewpoint

Entering the Danger Zone

Why Counselors Need to Find the Courage to Talk with Boys about Sex and Pornography

By John Sommers-Flanagan

For the most part, the United States lacks a coherent and systematic approach to sexual education. Instead, as lampooned in an online issue of The Onion, sex education is typically informal, unorganized, and inaccurate. The Onion article describes a scene in which a 10-year-old boy takes his 8-year-old cousin behind his parents’ garage with a page ripped out of a magazine and shares “the vast misguided knowledge of human sexuality he had gleaned from classmates’ hearsay as well as 12 minutes of a Real Sex episode he watched in a hotel room once.” The older boy recounts his rationale: “Every time people have sex the woman has a baby, and I just want [my younger cousin] to be completely prepared before getting naked with a girl.”

The good news about this is that The Onion is a fictional news source. The bad news is that the current state of sex education in our country isn’t much better than The Onion’s version.

Consider that a report this past April from the Centers for Disease Control and Prevention indicated that more than 80 percent of adolescents between the ages of 15 and 17 have no formal sexual education before actually having sex. If teenagers have no formal sex education, then what informal sex education do you suppose they take with them into their first sexual experiences?

One such source of informal sex education is pornography. In 2009, University of Montreal professor Simon Louis Lajeunesse designed a study to evaluate how pornography use affects male sexual development. He planned to interview 20 males who had viewed pornography and then compare their responses with those of 20 males who had never viewed porn. Remarkably, Lajeunesse had to abandon his project because he couldn’t find any college-aged males who hadn’t already viewed porn.

Other researchers report similar experiences. It appears that most boys, rather than learning about sex from a well-meaning, albeit uninformed cousin, get their information from the pornography industry … and my best guess is that the porn industry isn’t focusing on the best interests of American youth. This is one way in which reality may be worse than The Onion.

The absence of formal and accurate sexual education is a particularly American problem that may find its way into the offices of professional counselors. Many young males probably have very little basic knowledge or hold unhelpful ideas about sex and sexuality. Some will have porn addictions. Others will want to talk about how pornography may be affecting their real sex lives. You may also have clients who are concerned about their partner’s or potential partner’s porn viewing behaviors. Working with young (and older) males (and females) who want to talk about their sexual knowledge, beliefs and behaviors, including watching pornography, is both a challenge and an opportunity for professional counselors.

Counselors have an ethical mandate to strive toward competence. As articulated in the multicultural counseling literature, this requires cultivating personal awareness, gathering knowledge and developing skills.

Awareness: Expanding your comfort zone

Talking about sex, sexuality and sexual attraction can be difficult at every level. Think about yourself: How easy is it to talk about sex with your supervisor, colleagues, students, or clients? Your own experience may give you a glimpse into how challenging it can be to broach the topic of sex — even for professionals.

In comparison, it’s probably an understatement to say that it is especially difficult for boys to initiate a conversation about sex or sexuality with a professional counselor. This is why counselors who work with boys should become comfortable initiating conversations about sex. If you don’t ask at least a few gentle, polite, yet direct questions, you may be waiting a long time for the boy in your office to bring up the subject.

On the opposite extreme, some young clients will jump right into talking about sexuality and push us straight out of our comfort zones. Recently, I was working with a 16-year-old boy who described himself as a polyamorous “furry” (which I later learned involved sexualized role-playing as various animals). Admittedly, it was a challenge to maintain a nonjudgmental attitude. But without such an attitude, we wouldn’t have been able to have repeated open and useful conversations about his sexuality and sexual identity development.

Knowledge: The effects of pornography on boys and men

Many potential areas related to sexuality deserve attention, focus, and discussion in counseling. But because pornography and mixed messages about pornography are everywhere, it can be an especially important subject.

Most counselors probably believe that repeated exposure to pornography has a negative impact on male sexual development. This negative impact is likely exacerbated by the fact that most boys aren’t getting any organized, balanced, and scientific sexual information. Nevertheless, within the dominant American culture, there remains strong resistance to both sex education and pornography regulation. Even in a recent issue of Monitor on Psychology, the authors of an article questioned whether porn is addictive and blithely noted that “people like porn.”

It’s not surprising that porn has advocates. After all, it’s estimated to be a $6 billion-plus industry. In addition, media outlets explicitly and implicitly use pornlike sexuality to attract an audience and sell products. Recently, we’ve seen the increased use of hypermasculine male body types in the media, but most of the rampant sexual objectification still focuses on young female bodies.

Given that sexual development includes a complex mix of culture, biology and life experience, it’s not surprising that researchers have had difficulty isolating pornography as a single causal factor in male sexual developmental outcomes. However, a summary of the research indicates that as the viewing of pornography increases, so does an array of negative attitudes, behaviors, and symptoms. Generally, increased exposure to pornography is correlated with:
• More positive attitudes toward sexual aggression, increases in sexual aggression, multiple sexual partners, and engaging in paid sex
• Increased depression, anxiety and stress, and poorer social functioning
• Positive attitudes toward teen sex, adult premarital sex, and extramarital sex
• More positive attitudes toward pornography and more viewing of violent or hypersexual pornography
• Higher alcohol consumption, greater self-reported sexual desire, and increased rates of boys selling sexual acts

In contrast to these findings, a 2002 Kinsey Institute survey indicated that 72 percent of respondents considered pornography to be a relatively harmless outlet. This might be true for adults. I recall listening to B.F. Skinner talk about how older adults could use pornography as a sexual stimulant in ways similar to how they use hearing aids and glasses.

But the point isn’t whether people like porn or whether porn can be relatively harmless for some adults. The point is that pornography is a bad primary source of sexual information for developing boys and young men. As a consequence, it’s crucial for counselors who work with males to be knowledgeable about the potential negative effects of pornography.

Skills: How can counselors help?

A big responsibility for professional counselors who work with boys is to consistently keep sex and sexuality issues on the educational and therapeutic radar. This doesn’t mean counselors should be preoccupied with asking about sex. Rather, we should be open to asking about it, as needed, in a matter-of-fact and respectful manner.

As with most skills, asking about sex and talking comfortably about sexuality requires practice and supervision. But as Carl Rogers often emphasized, having an accepting attitude may be even more important than using specific skills. This implies that finding your own way to listen respectfully to boys (and all clients) about their sexual views and practices is essential. It also requires openness to listening respectfully even when our clients’ sexual views and practices are inconsistent with our personal values. As with other topics, if we ask about it, we should be ready to skillfully listen to whatever our clients are inclined to say next.

Case example
Some years ago, I had a young client named Ben who was in foster care. We began working together when he was 10 and continued intermittently until he was 17.
When Ben was around 13, I started routinely asking about possible romance in his life. He typically redirected the conversation. Occasionally he gave me a few hints that he wanted a girlfriend, but he mostly still seemed frightened of girls. As my counseling with Ben continued, I became aware that I had been conspiring with him to avoid talking directly about sex, possibly because I was afraid to bring it up.

I finally faced the issue when I realized (far too slowly) that Ben had no father figure in his life and, thus, I was one of his best chances at having a positive male role model. With encouragement from my supervision group, I was able to face my anxieties, do some reading about male sexual development, and finally broach the subject of having a sex talk with Ben.

Toward the end of a session I said, “Hey, I’ve been thinking we’ve never really talked directly about sex. And I realized that maybe you don’t have any men in your life who have talked with you about sex. So, here’s my plan. Next week we’re going to have the sex talk. OK?”

Ben’s face reddened and his eyes widened. He mumbled, “OK, fine with me.”

The next session I plowed right in, starting with a nervous monologue about why talking directly about sex was important. I then asked Ben where he’d learned whatever he knew about sex. He answered, “Sex ed at school, some magazines, a little Internet porn, and my friends.”

I felt a sense of gratitude that he was listening and being open, even if we were both feeling awkward. We talked about homosexuality, pornography, sexually transmitted diseases, pregnancy, contraception, and emotions. I tried to gently warn him that too much porn could become way too much porn. He agreed. He told me that he didn’t feel like he was gay but that he didn’t have anything against gays and lesbians. At the end of the conversation, we were both flushed. We had stared down our mutual discomfort and navigated our way through a difficult topic.

Professional sex educators emphasize that parents shouldn’t have just one sex talk with their kids; they should have many sex talks. What I thought was THE talk with Ben turned into something we could revisit. Over the next two years, Ben and I kept talking — off and on, here and there — about sex, sexuality, and pornography.

Final thoughts

Boys are a unique counseling population, and sex is a hot topic. Together, the two provide both challenge and opportunity for professional counselors. As counselors, we should work to develop our awareness, knowledge, and skills for talking with boys about sex and sexuality. You may not be the perfect sex educator, but when the alternatives for accurate information are pornography or someone’s uninformed older cousin, it becomes obvious that having open conversations about sex with boys is an excellent role for counselors to embrace.

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John Sommers-Flanagan is a counselor educator at the University of Montana and the author of nine books. Get more information on this and other topics related to counseling and parenting at johnsommersflanagan.com.

Letters to the editor: ct@counseling.org

SIDEBAR
Readings and resources for working with boys and men
• A Counselor’s Guide to Working With Men, edited by Matt Englar-Carlson, Marcheta P. Evans & Thelma Duffey, 2014, American Counseling Association
• “Addressing sexual attraction in supervision,” by Kirsten W. Murray & John Sommers-Flanagan, in Sexual Attraction in Therapy: Clinical Perspectives on Moving Beyond the Taboo — A Guide for Training and Practice, edited by Maria Luca, 2014, Wiley-Blackwell
• Guyland: The Perilous World Where Boys Become Men, by Michael Kimmel, 2010, Harper Perennial
• Tough Kids, Cool Counseling: User-Friendly Approaches With Challenging Youth, second edition, by John Sommers-Flanagan & Rita Sommers-Flanagan, 2007, American Counseling Association
• The Macho Paradox: Why Some Men Hurt Women and How All Men Can Help, by Jackson Katz, 2006, Sourcebooks
• The Good Men Project: goodmenproject.com

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

Non-Drug Options for Dealing with Depression

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Evidence supporting the efficacy of antidepressant medications continues to be weak. That doesn’t mean they never work; some individuals with depressive symptoms find them very helpful and that’s okay. But for many, antidepressant meds just don’t work very well . . . there are side effects and less than desirable antidepressant effects. This is why many people wonder: What are some of the best non-drug alternatives for treating symptoms of depression?

Here’s a short list that might be helpful.

1. Counseling or Psychotherapy: Going to a reputable and licensed mental-health professional who offers counseling or psychotherapy for depression can be very helpful. This may include individual, couple, or family therapy.

2. Vigorous aerobic exercise: Consider initiating and maintaining a regular cardiovascular or aerobic exercise schedule. This could involve a specific referral to a personal trainer and/or local fitness center (e.g., YMCA). In a recent small study of adolescents with clinical depression, 100% of the teens in the aerobic exercise group no longer met the diagnostic criteria for depression after receiving several months of exercise treatment.

3. Herbal remedies: Some individuals benefit from taking herbal supplements. In particular, there is evidence that omega-3 fatty acids (fish oil) and St. John’s Wort are effective in reducing depressive symptoms. It’s good to consult with a health-care provider if you’re pursuing this option.

4. Light therapy: Some people describe great benefits from light therapy. Specific information on light therapy boxes is available online and possibly through your physician.

5. Massage therapy: Research indicates some patients with depressive symptoms benefit from massage therapy. A referral to a licensed massage therapy professional is advised.

6. Bibliotherapy: Research indicates that some patients benefit from reading and working with self-help books or workbooks. The Feeling Good Handbook (Burns, 1999) and Mind over Mood (Greenberger and Padesky, 1995) are two self-help books used by many individuals.

7. Post-partum support: There is evidence suggesting that new mothers with depressive symptoms who are closely followed by a public-health nurse, midwife, or other professional experience fewer post-partum depressive symptoms. Additionally, new moms and all individuals suffering from depressive symptoms may benefit from any healthy and positive activities that increase social contact and social support.

8. Mild exercise and physical/social activities: Even if you’re not up to vigorous exercise, you should know that nearly any type of movement is an antidepressant. These activities could include, but not be limited to, yoga, walking, swimming, bowling, hiking, or whatever you can do! In the same exercise study mentioned above, 71% of the teenagers in the mild exercise group experienced a substantial reduction in their symptoms of depression.

9. Other meaningful activities: Never underestimate the healing power of meaningful activities. Activities could include (a) church or spiritual pursuits; (b) charity work; (c) animal caretaking (adopting a pet); and (d) many other activities that might be personally meaningful to you.

The preceding list is adapted from a tip-sheet in our book, “How to Listen so Parents will Talk and Talk so Parents will Listen.” See: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_9?s=books&ie=UTF8&qid=1413432346&sr=1-9
Or: http://lp.wileypub.com/SommersFlanagan/

John and his sister working on their positive emotions.

Peg and John Singing at Pat's Wedding

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

Neuro-counseling or Neuro-nonsense: You be the judge

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This is a Book Review written by a current doctoral student, Tara Smart and John SF. It was published this past June in the online journal, The Professional Counselor: http://tpcjournal.nbcc.org/

As you may detect, Ms. Smart and I are circumspect about the neuroscience bandwagon.

Here’s the review:

In A Counselor’s Introduction to Neuroscience, the authors claim that “neurocounseling” is the fifth force in the history of psychology and counseling. Although a precise and detailed definition of neurocounseling is elusive (both in this book and in the professional literature), it is described as the marriage of counseling and neurobiology. They offer a crash course in brain anatomy, function, and development in order to lay the groundwork for how neurocounseling can be used effectively with clients. Several chapters focus on the ways the brain is affected by certain mental disorders, and how specific counseling approaches address various brain regions and functions. The remainder of the book focuses on assessment of brain function and fictional cases to illustrate neurocounseling techniques. The chapters include numerous tables, figures, cases and opportunities to stop and reflect. The overall intent of the book is to arm counselors “with yet another highly effective and efficient way to help clients cope with (overcome, etc.) their personal psychological distress.”

Although the authors are clearly enamored with the interaction between neurobiology and counseling, they purposefully offer honest words of caution regarding the nascent and speculative nature of contemporary brain science. However, on occasion, they also make promising statements without citing scientific evidence and generalize results from animal studies (including rodents) to humans without offering their reasoning for doing so. As with any other resource, practitioners are responsible for weighing information and evaluating whether it is accurate and whether it will be helpful in their work. It is important to note that this book bills itself as an “introduction”—readers should not expect concrete or realistic examples of how professional counselors can use their new neuroscience knowledge to understand and enhance client functioning.

A Counselor’s Introduction to Neuroscience will help counselors begin to grapple with the implications of neuroscience for our profession. Although the neuroscience knowledge base that the authors provide is a good start, scientific rigor in terms of concrete application would be useful. Years from now, neurocounseling may well be a new force in counseling, but presenting it to the counseling community as an effective and efficient way to help clients today is premature. In the end, it is best to consider this book as a reasonable beginning and food for thought rather than a how-to guide for counselors seeking neurocounseling training. Hopefully in the ensuing years, there will be clearer guidance available to help professional counselors integrate neuroscience into their practice.

John using his Star Trek tricorder (cell phone) to do a quick selfie brain scan. The results were not promising.

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Suicide Assessment and Intervention

Suicide Assessment and Intervention for the 21st Century

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This past year, Alexander Street Press has been filming and producing a number of Ted-like talks focusing on counseling and psychotherapy. These are 15 minute talks, followed by a short Q & A on the topic. Below is a transcript from a talk I gave this summer in their studio at Governor’s State University in Chicago. I’m posting this talk in honor of National Suicide Prevention Day. This talk, and another couple dozen talks, should be available later this year or early next year from Alexander Street Press: http://search.alexanderstreet.com/counseling-therapy

Here’s the transcript:

Ironically I usually feel happy when I’m asked to do a talk on suicide and then I start with great confidence. I think it’s because suicide is such an extremely important and stressful issue for mental health professionals. But once I dive into the content, I remember how difficult this topic is. During one public presentation a therapist-friend of mine walked out because, as he told me later, the content was hitting too close to home. So please, as you listen, take care of yourself and talk to friends and colleagues for support.

To be perfectly honest, I DON’T REALLY LIKE to talk about suicide, but I think it’s VERY IMPORTANT that we do so directly . . . with each other and with our clients . . . and so here we go.

Death by suicide is pretty rare. Every year, only about 1 in 10,000 Americans commit suicide.

Despite its low frequency, suicide is still a major social problem that affects nearly everyone in one way or another. Over the years you’ve probably heard of many famous people who died by suicide. Marilyn Monroe and Kurt Cobain are two prime examples.

Perhaps even more important is the problem of suicide attempts. About 10% of the human population has attempted suicide and about 20% report struggling with suicidal thoughts and impulses. In surveys of high school students about 50% report “thinking about suicide.”

To summarize what we know about suicide base rates we can say:
I. Death by suicide is infrequent
II. Suicide attempts are NOT infrequent. In fact, many people attempt suicide and then go on to lead happy and meaningful lives
III. Suicide ideation (thoughts) are common
IV. And this is what makes suicide prediction very difficult, because it occurs so infrequently, but this is also what makes suicide prevention very necessary.

In 1991, I worked with a young man who ended up killing himself. This was a tragedy and I remember feeling that gut-wrenching guilt and regret that really stays with you a long time. Afterwards, my consultation group quizzed me and declared that I had done what I could, following all the standard and customary professional suicide assessment procedures. But in my mind and in my heart, then and now, I know I could have done better.

You see back in 1991, professionals (and the public) lived by a big suicide-related myth. We generally viewed suicidal thoughts as DEVIANCE. And so, when clients talked of suicide, it was our job to take action to assess and intervene to eliminate the suicidal thoughts.

This way of thinking about suicide is unhelpful. It creates distance between the professional therapist and his or her client; it also takes power away from clients. And so it’s NOW TIME FOR US TO BUST THE BIG SUICIDE MYTH.

NO LONGER should we consider suicidal thoughts and impulses simply as SIGNS OF DEVIANCE. Instead, we should view suicidal thoughts and impulses as normal signs of human distress. THIS IS THE NEW – and the more accurate – REALITY

Let’s take a minute now to contrast traditional and contemporary or post-modern suicide assessment and intervention approaches. The old Narrative is sort of a checklist approach where we emphasize risk factors, diagnostic interviewing, and no-suicide contracts. The New Narrative is different; it involves looking for protective factors, client strengths, normalizing suicide ideation, and initiating a collaborative safety plan.

This is what I wish I’d understood back in 1991. And so I’d like to be more specific about what I would have done differently and what all mental health professionals should be doing differently.
I wish I had asked more about his protective factors. Protective factors are things like reasons for living and so I wish I’d been more courageous in sitting with him and exploring the reasons why he wanted to live. I wish I’d asked him, over and over, what would or what could help him want to live.

I wish I had asked him more directly about what would help him control his suicide impulses. I would have asked him who he wanted around to help him. I would have lingered on this and asked, who else, what if that person can’t be there, who else would be your next choice to turn to for help.

One of the big changes in the suicide intervention field is that we no longer ask clients to sign No-Suicide contracts. Instead, we work to collaboratively develop a safety plan. As a part of this different focus, I wish I had clearly and unequivocally said to him: “I WANT YOU TO LIVE.” This is different than arguing with clients about their right or need to commit suicide. We should never argue against suicide because that can activate client resistance and make the act even more likely. But the language, “I WANT YOU TO LIVE” is just a self-disclosure and is therefore unarguable. It clearly communicates the intent to help.

Overall, I should have been MORE BALANCED and asked about what my client was doing when his depressive symptoms were gone. I should have asked about what he hoped for today and tomorrow and into the future. I should have asked him more about what brought a little light into his darkness. We should have brainstormed how to bring the light in when he was feeling down.
One problem with the old No-Suicide contracts is that clients sometimes viewed them as designed more to protect the counselor than the client. Obviously this is backward and not the sort of message we want to give clients who are suicidal. And so no-suicide contracts are out . . . and collaborative safety plans are in. What this requires is for counselors to dig in deeper and explore together specifically what the client is willing to do if the suicidal impulses come.

And now, because this talk is all about balancing negative and positive and I want to give an example of two suicide interventions, I’m going to share a positive story about suicide. Maybe I shouldn’t have said that, because now you already know there’s a happy ending. Oh well. Having a happy ending story is a good thing when you’re doing a suicide presentation.

About 5pm one evening I was about to head home and got a call from an alcohol and drug prevention organization across the street from where I was working. A suicidal 16-year-old had suddenly walked into their agency and they had no professional therapists on staff. They asked me to come over and help. I went right over and sat down with the girl in their lobby. We talked a while and she said she had left the local psychiatric unit and was planning to kill herself by jumping off a bridge about a quarter mile away. I listened and then began a specific suicide intervention developed by Edwin Shneidman, well-known as the father of suicidology. I said something like, “So you want to kill yourself. That’s one option, but let’s look at some others.” She said she wasn’t interested in any other options, but I got out a sheet of paper and wrote down “Kill myself” in the left hand column and asked her for other options. She said, “I don’t have any other options.” I said, how about going back to the hospital?” She said, “No way.” I said, that’s okay, we’re just making a list. Got any ideas? She said nothing. I said, “How about some family therapy?” She said, “No way.” I said, “Okay. I’ll write it down anyway because we’re just making a list. You don’t have to do any of these things.” Over time, I came up with about eight ideas of what she might do instead of kill herself, but she hadn’t come up with any. But the purpose of the intervention I was using was to address what Shneidman calls mental constriction. Mental constriction occurs when suicidal individuals are feeling so stressed and miserable that all they can consider is continued misery or death by suicide. With this intervention, I was working on opening up her mental blinders so she could see and consider alternatives to suicide. And so despite the fact that she didn’t generate or endorse any of the alternatives, I handed her the sheet of paper and asked her to rank order her preferences. And somewhat to my surprise, she ranked “Kill myself” as number three. There were two other options she preferred over suicide. I went for that and asked how I could help her get family therapy, which was her first choice. She re-escalated and headed out the door and down the street toward the bridge. I followed and walked with her and talked on and on about how “I want you to live.” She eventually got to the corner where we would cross the street to get on the bridge and I said I was stopping there. She stopped too and I reached out and grabbed her hand. She pulled back and yelled at me for touching her. Then I tried another specific suicide intervention, called Neodissociation. I said, “I know somewhere inside there’s a part of you that wants to live a happy and healthy life. Please, I want that part of you to just reach out and take my hand and walk with me back to the office so we can get you the help you deserve. She stared at me, reached out, took my hand, and then walked back to the office where I called the police and they took her back to the hospital.

[Insert big sigh here].

About two months later, I got a card from her that read, “The only bridges in my life now are bridges to health and happiness.” Now that’s a pretty good ending, but there’s more.

About six months later I asked her therapist if he thought it would be okay for me to interview her about what she thought was most helpful to her in choosing life over suicide. He asked her and then she came to my office for a short video interview. I remember asking her what was most helpful and she said she had a great student nurse at the hospital who was “Fresh” and genuine and that had helped a lot. Then I asked her what had helped her come with me on that first night we’d met. She said, “I’m not sure.” Eager for affirmation, I asked if it was when I used the neodissociation technique and she responded, “No way. That was really stupid.” Then she spontaneously said that she thought it was the look on my face, when I stopped and said I would go no further. She said that—in that moment—I looked like I really cared.

And so that’s the suicide story I prefer to remember.

Speaking of remembering, let’s review the main points.

In summary, there are three main modifications to the traditional approach, which I sometimes call the NEW MANTRA.
• There’s NO MORE BIG MYTH and so we normalize suicidal thoughts and impulses to counter our client’s feelings of deviance; they already feel deviant enough, we don’t need to add to that.
• Collaborate with clients. . . and be sure to do so from a place of genuine caring. It’s okay to say: “I WANT YOU TO LIVE” while collaboratively developing a safety plan.
• Use strength-based questioning, focusing on hope instead of hopelessness; meaning instead of meaninglessness.
• And of course, as always, like all good professionals, consult and document.

I’d like to end with a comment on self-care. As you can see in the final photo, my two daughters are engaged in what appears to be rather bizarre human behavior. I like to think of this as the one daughter performing a helpful “Pit-Check” for the other. We all need that and we especially need that when we’re working with clients who are suicidal. We need to keep talking and asking, “How am I doing?” We need to check up and check in with our colleagues and take very good care of ourselves because although the work we’re doing is essential . . . it can also be terribly stressful to face alone.

This reminds me of what another client once said to me. He said: The mind is a terrible place to go . . . alone . . . which is why we should keep on talking—directly to each other and to our clients—about suicide and suicide prevention.

Thanks for listening.

Ethics, Parenting

Handouts for the American Mental Health Counseling Association Conference

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These past two days I’ve been hanging out in Seattle with some very cool mental health counselors (as well as my very cool sister and her only mildly deranged husband). As a consequence, I promised to post these two powerpoint presentations to enable quick internet access. And so, if you were at the conference or you’re just a powerpoint presentation junkie, links to the two presentations are below:

1. Ethics: A Fresh Approach (two hour workshop with Rich Ponton — who is also very cool)

Ethics A Fresh Approach

2. How to Listen so Parents will Talk (three hour workshop)

How to Listen for AMHCA

Counseling and Psychotherapy Theory and Practice

Behavioral Activation Therapy: Let’s Just Skip the Cognitions

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This is a short excerpt from the text: Counseling and Psychotherapy Theories in Context and Practice

It describes a research-based behavioral approach to counseling and psychotherapy.

Over half a century ago, Skinner suggested that depression was caused by an interruption of healthy behavioral activities that had previously been maintained through positive reinforcement. Later, this idea was expanded based on the initial work of Ferster (1973) and Lewinsohn (1974; Lewinsohn & Libet, 1972). The focus was on observations that:

“. . . depressed individuals find fewer activities pleasant, engage in pleasant activities less frequently, and obtain therefore less positive reinforcement than other individuals.” (Cuijpers, van Straten, & Warmerdam, 2007, p. 319)

From the behavioral perspective, the thinking goes like this:
1.   Observation: Individuals experiencing depression engage in fewer pleasant activities and obtain less daily positive reinforcement.

2.   Hypothesis: Individuals with depressive symptoms might improve or recover if they change their behavior (while not paying any attention to their thoughts or feelings associated with depression).

Like the good scientists they are, behavior therapists have tested this hypothesis and found that behavior change—all by itself—can produce positive treatment outcomes among clients with depression. The main point is to get clients with depressive symptoms to change their behavior patterns so they engage in more pleasant activities and experience more positive reinforcement
Originally, behavioral activation was referred to as activity scheduling and used as a component of various cognitive and behavioral treatments for depression (A. T. Beck, Rush, Shaw, & Emery, 1979; Lewinsohn, Steinmetz, Antonuccio, & Teri, 1984). During this time activity scheduling was viewed as one piece or part of an overall cognitive behavior treatment (CBT) for depression.
However, in 1996, Jacobson and colleagues conducted a dismantling study on CBT for depression. They compared the whole CBT package with activity scheduling (which they referred to as behavioral activation), with behavioral activation (BA) only, and with CBT for automatic thoughts only. Somewhat surprisingly, BA by itself was equivalent to the other treatment components—even at two-year follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998; Jacobson et al., 1996).

As is often the case, this exciting research finding stimulated further exploration and research associated with behavioral activation. In particular, two separate research teams developed treatment manuals focusing on behavioral activation. Jacobson and colleagues (Jacobson, Martell, & Dimidjian, 2001) developed an expanded BA protocol and Lejuez, Hopko, Hopko, and McNeil (2001) developed a brief (12 session) behavioral activation treatment for depression (BATD) manual and a more recent 10 session revised manual (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011).

Implementation of the BATD protocol is described in a short vignette later in the behavioral theory and therapy chapter in the text: Counseling and Psychotherapy Theories in Context and Practice by John and Rita Sommers-Flanagan. See: http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470617934.html

Or, on Amazon: http://www.amazon.com/John-Sommers-Flanagan/e/B0030LK6NM/ref=ntt_dp_epwbk_1

Several people engaging in behavioral activation therapy at a wedding.

Dancing

 

Uncategorized

Upcoming Webinar: Engaging and Treating Youth with ODD and CD

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Tomorrow at noon Mountain time I’ll be doing a one-hour webinar titled: Engaging and Treating Youth with Oppositional Defiant Disorder and Conduct Disorder (and their Parents). This webinar is hosted by Western Montana Addictions Services. The webinar link for Tuesday, June 10th at noon (MST) is:

https://sas.elluminate.com/m.jnlp?sid=2008093&username=&password=M.5473E398E968F03FF120D04D57D5CF
Conference call line and pin: 571-392-7703 PIN: 832 106 441 879

Join in if you can. I’ll post the powerpoints for the webinar later today or tomorrow.

Happy Monday.

IMG_3098

 

Cool Counseling, Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

Tough Kids, Cool Counseling PowerPoints from SDMHCA May 1 Workshop

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Attached to this post are the handouts from the May 1 “Tough Kids, Cool Counseling” workshop in Spearfish, South Dakota.

It was a great day with about 85 wonderful, amazing, and exceptionally nice school and mental health counselors from throughout South Dakota.

This is the powerpoint:

SDMHCA Workshop 14 Part No Cartoons

And this is the supplementary handout:

SDMHCA TKCC Part II Supplement

I hope this information is helpful!

John SF

 

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

Handling Termination in Counseling and Psychotherapy

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

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

Termination Content Checklist

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

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

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

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