Tag Archives: Counseling

Counseling and Psychotherapy Theory and Practice, Divorce, Group therapy, Parenting, Uncategorized

The Love Reframe

8 Comments

 

Years ago I had the privilege and challenge of teaching a class for divorced parents through Families First in Missoula. About half of the dozen or so participants were mandated to attend. This made for an initially less-than-pleasant opening mood. As I went around the room doing introductions, I came to a man who looked a bit snarly. He announced his name and then said, “But I don’t need no stupid-ass parenting class. The only reason I’m here is because the Judge told me that if I didn’t come, I’d be forced to have supervised visits with my 12 year-old daughter. I’m here, but I don’t need this stupid-ass class.”

 

This was a difficult moment and perhaps because I’m a man, complete with a pesky “Y” chromosome, I was tempted to get into an instant pissing match right there. I felt an urge to say something like, “Well, you may not think you need this class, but apparently the Judge does and so you’d better watch how you talk in here!” Instead, somewhat to my surprise, the following words came into my mind and then out of my mouth, “Well, let me especially thank you for coming because you must really love your daughter to be willing to attend this class.”

 

As the 6 hour marathon class progressed, the snarly man settled in. He was never really pleasant, but he contributed to discussions and politely got in line at the end of class to receive his signed certificate. When I handed him the certificate, I said something like, “Hey, you know you should frame this certificate and put it on your wall at home.”

 

A few weeks after the class I got a call from the guy who didn’t need a stupid-ass parenting class. He sounded different and immediately apologized for “being a jerk in class.” Then he told me in a cracking voice that he’d taken my advice and hung the class certificate on his wall. And then it was clear he was crying when he said, “My daughter came over for an unsupervised visit and when she saw that certificate on the wall, she turned around and gave me this big old hug and said, Daddy, I am so proud of you!”

 

This experience and others like it taught me an important lesson about parents in general and fathers in particular. I’ve learned that underneath the bluster of some irritable and difficult dads there are men who desperately love their children. If we tap this potential, good things can happen.

Therapy with Adolescents

Information on Suicide Interventions for Counselors

2 Comments

The following information is excerpted from the soon-to-be-forthcoming 5th edition of Clinical Interviewing, published by John Wiley & Sons. This includes information that I didn’t get a chance to cover during my ACA pre-conference Learning Institute yesterday. For information on the Clinical Interviewing text, see:  http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=dp_ob_title_bk

Safety Planning

The primary thought disorder in suicide is that of a pathological narrowing of the mind’s focus, called constriction, which takes the form of seeing only two choices; either something painfully unsatisfactory or cessation of life. (Shneidman, 1984, pp. 320–321)

Helping clients develop a thoughtful and practical plan for coping with and reducing psychological pain is a central component in suicide interventions. This plan can include relaxation, mindfulness, traditional meditation practices, cognitive restructuring, social outreach, and other strategies that increase self-soothing, decrease social isolation, and decrease the sense of being a social burden (Joiner, 2005).

Instead of the traditional approach of implementing no-suicide contracts, contemporary approaches emphasize obtaining a commitment to treatment statement from the client (Rudd et al., 2006). These treatment statements or plans go by various names including, “Commitment to Intervention,” “Crisis Response Plan,” “Safety Plan,” and “Safety Planning Intervention” (Jobes et al., 2008; Stanley & Brown, 2012); they’re more comprehensive and positive in that they describe activities that clients will do to address their depressive and suicidal symptoms, rather than focusing narrowly on what the client will not do (i.e., commit suicide). These plans also include ways for clients to access emergency support after hours (such as the national suicide prevention lifeline 1(800) 273-TALK or a similar emergency crisis number; Doreen Marshall, personal communication, September 30, 2012).

As a specific safety planning example, Stanley and Brown (2005) developed a brief treatment for suicidal clients, called the Safety Planning Intervention (SPI). This intervention was developed from evidence-based cognitive therapy principles and can be used in hospital emergency rooms as well as inpatient and outpatient settings (Brown et al., 2005). The SPI includes six treatment components:

  1. Recognizing  warning  signs of an  impending suicidal crisis
  2. Employing  internal coping  strategies
  3. Utilizing social contacts as a means of distraction  from suicidal  thoughts
  4. Contacting  family   members   or friends who may help to resolve the crisis
  5. Contacting mental health  professionals or agencies
  6. Reducing the  potential use of lethal  means (Stanley & Brown, 2012, p. 257)

Stanley and Brown (2012) noted that the sixth treatment component, reducing lethal means, isn’t addressed until the other five safety plan components have been completed. Component six also may require assistance from family members or a friend, depending on the situation.

Identifying Alternatives to Suicide

Suicide is a possible alternative to life. Engaging in a debate about the acceptability of suicide or whether with clients with suicidal impulses “should” seek death by suicide can backfire. Sometimes suicidal individuals feel so disempowered that the threat or possibility to take their own life is perceived as one of their few sources of control. Consequently, our main job is to help identify methods for coping with suicidal impulses and to identify life alternatives that are more desirable than death by suicide—rather than taking away clients’ rights to consider death by suicide.

Suicidal clients often suffer from mental constriction and problem-solving deficits; they’re unable to identify options to suicide. As Shneidman (1980) suggested, clients need help to improve their mood, regain hope, take off their constricting mental blinders, and “widen” their view of life’s options.

Shneidman (1980) wrote of a situation where a pregnant suicidal teenager came to see him in a suicidal crisis. She said she had a gun in her purse. He conceded to her that suicide was an option, while pulling out paper and a pen to write down other life options. Together, they generated 8-10 alternatives to suicide. Even though Shneidman generated most of the options and she rejected them, he continued writing them down, noting they were only options. Eventually, he handed the list over to her and asked her to rank order her preferences. It was surprising to both of them that she selected death by suicide as her third preferred option. As a consequence, together they worked to implement options one and two and happily, she never needed to choose option three.

This is a practical approach that you can practice with your peers and implement with suicidal clients. Of course, there’s always the possibility that clients will decide suicide is the best choice (at which point you’ve obtained important assessment information). However, it is surprising how often suicidal clients, once they’ve experienced this intervention designed to address their mental constriction symptoms, discover other, more preferable options that involve embracing life.

Separating the Psychic Pain From the Self

Rosenberg (1999; 2000) described a helpful cognitive reframe intervention for use with suicidal clients. She wrote, “The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self” (p. 86). This technique can help suicidal clients because it provides much needed empathy for the clients’ psychic pain, while at the same time helping them see that their wish is for the pain to stop existing, not for the self to stop existing.

Similarly, Rosenberg (1999) recommended that therapists help clients reframe what’s usually meant by the phrase “feeling suicidal.” She noted that clients benefit from seeing their suicidal thoughts and impulses as a communication about their depth of feeling, rather than an “actual intent to take action” (p. 86). Once again, this approach to intervening with suicidal clients can decrease clients’ needs to act, partly because of the elegant cognitive reframe and partly because of the therapist’s empathic message.

And here’s a photo of the cover of the Tough Kids, Cool Counseling book. You can get this through ACA or on Amazon: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_3?ie=UTF8&qid=1363881381&sr=1-3

Tough Kids Image

Personal Reflections, Therapy with Adolescents

ACA Conference in Cincinnati: Day One

2 Comments

Yesterday was Day One of my American Counseling Association conference experience and it has led me to notice that whenever I dish up my plate, it always seems there’s a little food that falls off the edges. My grandmother used to say my eyes were bigger than my stomach, but that’s silly because I’ve looked at my stomach; if my eyes really were bigger, I’d look like a brother from another planet. Obviously, this is a metaphor.

The point is that I always try to fit too much material into my presentations. Yesterday I presented a 6 hour “Learning Institute” titled, “Counseling Challenging Teenagers.” It was a very nice experience with about 20 participants who care enough about working with teenagers to show up in Cincinnati 2 days before the conference actually starts for a spendy workshop. I was impressed with the participants and the questions and the dedication to learning and serving teenagers. Very cool.

However, not surprisingly, because as Robert Frost would undoubtedly contend, my reach consistently exceeds my grasp, I didn’t quite fit every part of the workshop content into the workshop . . . which brings me to the purpose of this post . . . which is to describe my next two postings . . . which will be on alternative to suicide and neodissociation as a suicide intervention . . . which were the two parts of the workshop that exceeded my grasp.

Highlights of Day One: The man who drove 18 hours from Maryland to attend (and managed to mostly stay awake); the woman who helped with the workshop as a volunteer and then was super-giddy about getting me to take a photo of her with Bob Wubbolding (and then, I think to humor me, acted excited to include me in an additional photo with the two of them); finding a Starbucks, Panera Bread, and Chipotle within blocks of the Convention Center.

More soon.

 

Counseling and Psychotherapy Theory and Practice

Through the Anger Looking Glass

2 Comments

This blog was originally posted on the psychotherapy.net website this past week. Psychotherapy.net is a great resource for counselors and psychotherapists . . . http://www.psychotherapy.net/blog/title/through-the-anger-looking-glass

Through the Anger Looking Glass

By John Sommers-Flanagan

A couple weeks ago on NPR’s “Weekend Edition,” the focus was on the 50th anniversary of Betty Freidan’s The Feminine Mystique. In this book Friedan raged against the status of women in the 1960s. Although millions of people have read this feminist manifesto, it seems very few presently understand how anger in general and Friedan’s anger in particular could be a source of insight, motivation, and personal and social transformation.

Anger is an emotional state that has a bad rap. There’s far more written about anger control (“anger management”) than about how anger, when nurtured and examined, can transform. As most mental health professionals already know, anger is an emotion, not a behavior. And emotions are acceptable and desirable. When anger fuels aggressive or destructive behavior is when it becomes problematic.

But since everyone already knows about and talks about the destructive capability of anger—let’s talk about the constructive side of this emotion instead. Hardly anyone articulates anger’s positive qualities as clearly as the feminists. Feminist therapists consider “encouraging anger expression” as a meaningful process goal in psychotherapy for at least five reasons:

  1. Girls and women are typically discouraged from expressing anger directly. Experiencing and expressing anger without repressive cultural consequences can be an exhilarating freedom for females. Similarly, experiencing anger, but not letting it become aggression, is a new and productive process for males.
  2. Anger illuminates. There’s nothing quite like the rush of anger as a signal that something is not quite right. Examined anger can stimulate insight.
  3. Alfred Adler suggested that the purpose of insight in psychotherapy was to enhance motivation. Anger is helpful for both identifying psychotherapy goals AND for mobilizing client motivation.
  4. During psychotherapy anger may occur in-session towards the psychotherapist. Skillful therapists accept this anger without defensiveness and then collaboratively explore the meaning of in-session anger.
  5. Anger is a natural emotional response to oppression and abuse. If clients consistently suppress anger, it inhibits them from experiencing their full range of humanity.

For feminists, one goal of nurturing and exploring client anger is to facilitate feminist consciousness. Feminist consciousness involves females (and males) developing greater awareness of equality and balance in relationships. However, using anger to stimulate insight and motivation is useful in all forms of therapy, not just feminist therapy.

But working with (and not against) anger in psychotherapy is complex. The problem is that anger pulls so strongly for a behavioral response. Reactive anger is destructive. Clients want to let it out. Experiencing and expressing anger feels so intoxicatingly right. Clients want to punch walls. They want to formulate piercing insults. They want to counterattack. Unexamined anger is reactive and vengeful.

Imagine a male client. He’s uncomfortable with how his romantic partner has been treating him. You help him explore these feelings and identify the source; he recognizes that his partner has been treating him disrespectfully. But good psychotherapy doesn’t settle for simple answers. His new insight without further exploration could stimulate retaliatory impulses. Good psychotherapy stays with the process and examines aggressive outcomes. It helps clients explore alternatives. Could he be overreacting? Perhaps the anger is triggering an old wound and it’s not just the partner’s behavior that’s triggering the anger?

Relationships are nearly always a complex mix of past, present, and future impulses and transactions. When anger is respected as a signal and clients take ownership of their anger, good things can happen. It can be used to help clients become more skilled at identifying and articulating underlying sadness, hurt, and disappointment. Clients can emerge from psychotherapy with not only new insights, but increased responsibility for their behavior and more refined skills for communicating feelings and thoughts without blaming anger, but in a way that serves as an invitation for greater intimacy and deeper partnership.

None of this would be possible without the clarifying stimulation of anger and a collaborative psychotherapist who’s able to help clients face, embrace, and understand the many layers of meaning underneath your anger. And it’s about time we learned a lesson from the feminists and started giving anger the respect it deserves.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Exploring Empathy — Part I

Leave a comment

Happy Saturday. This post is the first of a three-part preview of our discussion on Empathy from Clinical Interviewing, 5th Edition.

See: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=ntt_at_ep_dpt_1

Empathic Understanding

Empathic understanding is a central concept in counseling and psychotherapy. Rogers (1980) defined empathy as:

. . . the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. [It is] this ability to see completely through the client’s eyes, to adopt his frame of reference, (p. 85) . . .  It means entering the private perceptual world of the other . . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . . . It means sensing meanings of which he or she is scarcely aware. (p. 142)

Rogers’s definition of empathy is complex. It includes several components.

  • Therapist ability or skill
  • Therapist attitude or willingness
  • A focus on client thoughts, feelings, and struggles
  • Adopting the client’s frame of reference or perspective-taking
  • Entering the client’s private perceptual world
  • Moment-to-moment sensitivity to felt meanings
  • Sensing meanings of which the client is barely aware

A Deeper Look at Empathy

As with congruence and unconditional positive regard, the complexity of Rogers’s definition has made research on empathy challenging. Many different definitions of empathy have been articulated (Batson, 2009; Clark, 2010; Duan & Hill, 1996). According to Elliott, Bohart, Watson, & Greenberg (2011), recent advances in neuroscience have helped consolidate empathy definitions into three core subprocesses:

  1. Emotional simulation: This is a process that allows one person to experientially mirror another’s emotions. Emotional simulation likely involves mirror neurons and various brain structures within the limbic system (e.g., insula).
  2. Perspective-taking: This is a more intellectual or conceptual process that appears to involve the pre-frontal and temporal cortices.
  3. Emotion regulation: This involves a process of re-appraising or soothing of one’s own emotional reactions. It appears to be a springboard for a helping response. Emotional regulation may involve the orbitofrontal cortex and prefrontal and right inferior parietal cortices.

Empathy is an interpersonal process that requires experiencing, inference, and action. In chapter 1 we noted that playing a note on one violin will cause a string on another violin to vibrate as well, albeit at a lower level. In therapy, this has been referred to as resonance. Most people have had the experience of feeling tears well up at a movie or while someone talks about pain or trauma. This is the experiential component of empathy that Elliot et al., (2011) referred to as emotional simulation).

Beyond this physical/experiential resonance, one person cannot objectively know another person’s emotions and thoughts. Consequently, at some level, empathy always involves subjective inference. This process has been referred to as perspective-taking in the scientific literature and is considered a cognitive or intellectual requirement of empathy (Stocks, Lishner, Waits, & Downum, 2011).

Empathy—at least within the context of a clinical interview—also requires action. Therapists must cope with and process the emotions that are triggered and then provide an empathic response. Most commonly this involves reflection of feeling or feeling validation, but nearly every potential interviewing response or behavior can include verbal and nonverbal components that include empathy. The action component of empathy is likely what Elliot et al., are referring to with the term emotional regulation.

Simple guides to experiencing and expressing empathy can help you develop your empathic abilities. At the same time, we don’t believe any single strategy will help you develop the complete empathy package. For example, Carkhuff (1987) referred to the intellectual or perspective-taking part of empathy as “asking the empathy question” (p. 100). He wrote:

By answering the empathy question we try to understand the feelings expressed by our helpee. We summarize the clues to the helpee’s feelings and then answer the question, How would I feel if I were Tom and saying these things? (p. 101).

Carkhuff’s empathy question is a useful tool for tuning into client feelings, but it also oversimplifies the empathic process in at least two ways. First, it assumes therapists have a perfectly calibrated internal affective barometer. Unfortunately this is not the case as clients and therapists can have such different personal experiences that the empathy question produces completely inaccurate results; just because you would feel a particular way if you were in the client’s shoes doesn’t mean the client feels the same way. Sometimes empathic responses are a projection of the therapist’s feelings onto the client. If you rely solely on Carkhuff’s empathy question, you risk projecting your own feelings onto clients.

Consider what might happen if a therapist tends towards pessimism, while her client usually puts on a happy face. The following exchange might occur:

Client: “I don’t know why my dad wants us to come to therapy now and talk to each other. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would accept it too.”

Therapist: “It must make you angry to have a father who can’t communicate effectively with you.”

Client: “Not at all. I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”

In this case, asking the empathy question: “How would I feel if I could never communicate well with my father?” may produce angry feelings in the therapist. This process consequently results in the therapist projecting her own feelings onto the client—which turns out to be a poor fit for the client. Accurate empathic responding stays close to client word content and nonverbal messages. If this client had previously expressed anger or was looking upset or angry (e.g., angry facial expression, raised voice), the therapist might resonate with and choose to reflect anger. However, instead the therapist’s comment is inaccurate and is rejected by the client. The therapist could have stayed more closely with what her client expressed by focusing on key words. For example:

Coming into therapy now doesn’t make much sense to you. Maybe you used to have feelings about your lack of communication with your dad, but it sounds like at this point you feel pretty numb about the whole situation and just want to move on.

This second response is more accurate. It touches on how the client felt before, what she presently thinks, as well as the numbed affective response. The client may well have unresolved sadness, anger, or disappointment, but for the therapist to connect with these buried feelings requires a more interpretive intervention. Recall from Chapter 3 that interpretations and interpretive feeling reflections must be supported by adequate evidence.

To help with the intellectual process of perspective-taking, instead of focusing exclusively on what you’d feel if you were in your client’s shoes, you can expand your repertoire in at least three ways:

  1. Reflect on how other clients have felt or might feel
  2. Reflect on how your friends or family might feel and think in response to this particular experience
  3. Read and study about experiences similar to your clients’.

Based on Rogers’s writings, Clark (2010) referred to intellectual approaches to expanding your empathic understanding as objective empathy. Objective empathy involves using “theoretically informed observational data and reputable sources in the service of understanding a client” (Clark, 2010, p. 349). Objective empathy is based on the application of external knowledge to the empathic process—this can expand your empathic responding beyond your own personal experiences.

Rogers (1961) also emphasized that feeling reflections should be stated tentatively so clients can freely accept or dismiss them. Elliot et al., (2011) articulated the tentative quality of empathy very well: “Empathy should always be offered with humility and held lightly, ready to be corrected” (p. 147)

From a psychoanalytic perspective, it’s possible to show empathy not only for what clients are saying, but also for their defensive style (e.g., if they’re using defense mechanisms such as rationalization or denial, show empathy for those):

Client: “I don’t know why my dad wants us to come to therapy now. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would.”

Therapist: “Coming into therapy now doesn’t make much sense to you. Maybe you had feelings about your lack of communication with your dad before, but it sounds like you feel pretty numb about the whole situation now.”

Client: “Yeah, I guess so. I think I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”

Therapist: “Maybe one of the ways you protect yourself from feeling anything is to distance yourself from your parents. Otherwise, it could still bother you, I suppose.”

Client: “Yeah. I guess if I let myself get close to my parents again, my dad’s pathetic inability to communicate would bug me again.”

This client still has feelings about her father’s poor communication. One of the functions of accurate empathy is to facilitate the exploration of feelings or emotions (Greenberg, Watson, Elliot, & Bohart, 2001). By staying with the client’s feelings instead of projecting her own feelings onto the client, the therapist is more likely to facilitate emotional exploration.

A second way in which Carkhuff’s (1987) empathy question is simplistic is that it treats empathy as if it had to do only with accurately reflecting client feelings. Although accurate feeling reflection is an important part of empathy, as Rogers (1961) and others have discussed, empathy also involves thinking and experiencing with clients (Akhtar, 2007). Additionally, Rogers’s use of empathy with clients frequently focused less on emotions and more on meaning. Recall that in his original definition, Rogers wrote that empathy involved: “. . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . .” (p. 142). And so empathic understanding is not simple, it involves feeling with, thinking with, sensing felt meanings, and reflecting all this and more back to the client with a humility that acknowledges deep respect for the validity of the client’s own experiences.

More to come on this tomorrow in “Exploring Empathy” Part II.

References

Akhtar, S. (Ed.). (2007). Listening to others: Developmental and clinical aspects of empathy and attunement Lanham, MD, US: Jason Aronson.

Carkhuff, R. R. (1987). The art of helping (6th ed.). Amherst, MA: Human Resource Development Press.

Clark, A. J. (2010). Empathy: An integral model in the counseling process. Journal of Counseling & Development, 88, 348-356.

Greenberg, L. S., Watson, J. C., Elliot, R., & Bohart, A. C. (2001). Empathy. Psychotherapy: Theory, Research, Practice, Training, 38(4), 380-384.

Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.

Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.

Stocks, E. L., Lishner, D. A., Waits, B. L., & Downum, E. M. (2011). I’m embarrassed for you: The effect of valuing and perspective taking on empathic embarrassment and empathic concern. Journal of Applied Social Psychology, 41(1), 1-26. doi: http://dx.doi.org/10.1111/j.1559-1816.2010.00699.x

 

Counseling and Psychotherapy Theory and Practice

From Boring Theory to Exciting Practice: WACES PowerPoints II

Leave a comment

Mondays are my theories evening this semester. Last night was feminist theory and therapy. We rocked our way through Women & Madness; Kinder, Kuche, and Kurche; and the Broverman et al. study to provide us with a foundation of justified anger which helped raise our collective consciousness and stimulate our instinct to tend and befriend and eventually develop an ethic of caring.

Below is the link to powerpoints from my second presentation at the WACES conference in Portland.

WACES Theories

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

Introductions and Full Disclosure (at least in part)

6 Comments

When people ask me what I do for work, I often tell them I have the best job in the world; then I describe it to them: “Every spring our faculty intensely screens a group of about 50 applicants to our graduate programs in counseling down to about 20 students who are admitted. And then I have the summer off. And then the new group of students show up in the fall and they’re all smart and kind and compassionate and because they’re graduate students, they’re motivated and focused and they want to attend class and become the best darn counselors they can become. And then, when I have them in class I’m with this group of incredibly socially skilled and sensitive, nice people and they make eye contact, nod their heads, act like they’re listening to me, and laugh at my jokes and stories.” Pretty much after I describe this scenario whoever asked me the question has either walked away or has crumpled into a heap on the floor racked with pain and jealousy.

This past Friday I got to teach my first full-day class with our new students. And just like Mary Poppins, they were practically perfect in every way.

Students in our graduate programs school and mental health counseling have a plethora of opportunities to engage in role-plays. As you may guess, these opportunities may or may not be met with great enthusiasm. More often than not we suggest to our students that they think of a minor problem in their lives, exercise censorship, and actually play themselves in these role-play encounters. This is totally fun . . . at least for the faculty.

Because we ask so much from our students—we expect them to “bring it” every hour of every class—at the beginning we offer our first year graduate students an activity where they can come to the front of the room as ask faculty members any question they’d like. This is totally fun . . . at least for the students.

On Friday, I had the added joy of listening as our two newest faculty members, Dr. Kirsten Murray and Dr. Lindsey Nichols, got quizzed by the new students. It was fabulous. I was filled with pride and happiness over having colleagues who are amazing and cool. Then it was my turn.

Somehow, the very first question turned into an awkward explanation of my professional status. I’m pretty old and I’ve answered a gazillion student questions about myself over the years, but I still felt the inner warmth, the sudden presence of sweat on my skin, and that funny feeling of hearing my own voice from a distance (totally fun!).

The problem is that I’m trained as a clinical psychologist and I teach in a counselor education program. To some people, this is like blasphemy. It’s like I was born in the country of clinical psychology and immigrated to the country of counselor education. At some tiny level, I sense how it might feel to be in the marginalized category of acculturation. Sometimes, under stress, I start speaking the language of clinical psychology (one time at an editorial board meeting of the Journal of Counseling and Development I accidentally said “A-P-A” instead of “A-C-A” and thought for sure I might be stoned; but everyone acted like they didn’t notice; of course, they also acted like they didn’t notice me after the meeting—or maybe I was just imagining that and isolating myself?).

I love my country of origin—the country of clinical psychology. I could talk about Rorschach cards and what it means for me to have a spike 5 and subclinical 6-9 profile on my MMPI for days. Studying psychopathology was like the coolest thing ever.

But I also love the country I’ve immigrated to. I have pleasant flashbacks of my first ACA conference back in 1992 when I volunteered to participate in a group counseling demonstration with Jerry and Marianne Corey. They were fabulous and I was hooked. I still like going to APA conferences, but for me, ACA conferences are a little less anal and a little more fun. I mean like one time I got my photo taken with William Glasser and last year I got it taken with Robert Wubbolding. They’re starting to think of me like a Reality Therapy groupie. What’s not cool about that?

The problem is that some members of ACA and APA don’t really like each other all that well. And neither of them really like the NASW or that evil “other” APA. The turf issues around professional discipline strike me as silly and overdone. I’m pretty sure that at this point I’m completely unemployable as an academic anywhere but the University of Montana. Psychology departments wouldn’t touch me because of my counseling cooties and Counseling departments now have to abide by a rule where they can’t hire anyone who doesn’t have a doctorate in counselor education. This would be pretty funny stuff if it weren’t so ridiculous. Psychologists want prescription privileges, Counselors want to do psychological evaluations, Social Workers want to do everything and anything, and yet, in many ways, we’re all more alike than we are different. I’ve got no solutions here . . . just observations.

And so in the beginning I experienced only a mild dissociative episode as I squeezed out my full disclosure—admitting before God and the class and my fellow professors that I am, in fact, BOTH a clinical psychologist AND a counselor educator. And in the end, it felt good. We had more discussions and questions later and no one (at least while I was looking) made the sign of the cross and shrunk away. I was just part of an amazing group of people who want to help other people live happier and more fulfilling lives. It could have been a group of students studying psychology or social work or counseling or maybe even all three at once . . . . It was really very nice.

John Dancing at a Wedding Reception

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections

Teaching Counseling and Psychotherapy Theories: Reflections on Week 1

2 Comments

Teaching Counseling and Psychotherapy Theories – Week 1

This past Monday evening in Missoula, Montana I met with my 80+ counseling and psychotherapy theories students for our first 3-hour class of the semester. Some student might have thought they’d get out early on the first day of the semester . . . but such was not the case. We had a nice evening together (my opinion). Although it was smoky outside (too many forest fires nearby) in the classroom the air was clear and the thinking sharp. Every year it feels humbling when I meet a new group of students in the fall and recognize their dedication and intelligence, not to mention the compassion for and interest in helping others that’s an intrinsic requirement of taking a class that’s all about counseling and psychotherapy theories and practice.

This group was especially generous – laughing heartily at my stories and gently confronting me when I misspoke and suggested I might spontaneously lie to protect my client’s confidentiality. One of my favorite moments was when, as we were talking about strategies for protecting client confidentiality in a public situation where someone might ask, “How do you know ______?” Several students shared excellent strategies (far better than my ‘spontaneous lying’ idea). One in particular said, “I just don’t respond to the question and make some comment like ‘Oh yeah, you know she’s really good at soccer’ and then hardly anyone follows that up by asking me how I know that person a second time.” Somewhat surprisingly, I was able to use that particular line several times later in class whenever students asked me questions I couldn’t answer. You should try it. Here’s how it works: Somebody asks you something you can’t or don’t want to answer, just say, “Hey, you know she’s really good at soccer.” It’s pretty much guaranteed you won’t have to answer the question.

As a method of providing a little extra intellectual stimulation, below I’m including two activities that go along with the content of Counseling and Psychotherapy Theories in Context and Practice. Have fun and good luck in your personal quest for better understanding of yourself and others . . . a particular quest that never really ends.

Activity 1: Creating and Testing Personal Hypotheses

One of our graduate students told us his “personal theory” of why some people become good cooks and other people develop poor cooking skills. He said:

I’m a bad cook because my mom was a good cook. I never had any reason to learn to cook because my mom did it all for us. But my girlfriend is a really good cook. I think that’s because her mom was a bad cook and so she had more reason to learn to cook for herself.

Although you can probably see a number of flaws with the reasoning underlying this “theory,” most of us carry these sorts of ideas around with us all the time. Let’s briefly analyze and test our student’s theory and then move on to identifying some of yours.

First, we should ask: Is this student’s statement really a theory? The answer is “No.” The reason this isn’t a theory is because it’s too narrow and not very elaborate. Theories don’t just predict behavior, they also provide detailed explanations for why particular behaviors occur.

As described in the text, a theory involves a gathering together and organizing of knowledge about a particular object or phenomenon. Also, theories are used to generate hypotheses about human thinking, emotions, and behavior.  Although our student has developed an interesting hypothesis about one factor that contributed to why he and his girlfriend have poor and good cooking skills, he really doesn’t have an overarching theory for generating the hypothesis . . . but he could develop one. Perhaps his bigger theory is about how individuals compensate for their caregivers strengths and weaknesses. He would need to work on describing, explaining, and predicting how this process works, but his idea has potential.

Theorists work both deductively (from the theory to the hypothesis) and inductively (from the specific hypothesis or observation to the bigger theory). Our student appears to be operating inductively. He observed himself and he observed his girlfriend and he developed an interesting hypothesis.

It’s possible and reasonable for people to systematically test their personal theories or hypotheses. Most likely, if we asked our student to test his hypothesis, he would do so in a biased way. He would likely notice when his hypothesis is true and ignore or completely overlook evidence opposing his hypothesis. Social psychology has shown that humans just seem to operate that way . . . we look for evidence to support our ideas and ignore evidence that contradicts our ideas (see Snyder & Swann, 1978).

With all this in mind, take a few minutes to write down some of your personal hypotheses about human behavior. Pick anything that you tend to think is true about humans (e.g., women have greater pain tolerance than men; individuals from larger families have better social skills; pet owners have trouble relating to people) and describe it below.

Hypothesis 1:

 

Hypothesis 2:

 

Hypothesis 3:

 

After you’ve established a few hypotheses, think about whether they might fit together into an overarching theory—or are they just a few random and unconnected ideas about human behavior? Then, either way, think about how you might test the validity of your hypotheses. Also, think about how you could or would avoid being systematically biased toward validating your own hypotheses?

Activity #2: A Psychological Assessment Critique

Years ago, Rita had a cartoon on her office door that had two guys in their scientific lab coats in conversation. One of the guys was asking the other one something like: “Would you like me to come up with evidence to destroy this scientific argument or evidence to support it?”

The big point of the cartoon is that even science is subjective. Because science is subjective, it’s important to be able to criticize research in general and or own research in particular. For this activity, we’d like you to list five shortcomings or problems with measuring counseling and psychotherapy outcomes. For example, let’s pretend you’ve just conducted 10 sessions of therapy with a client. You’re interested in measuring your effectiveness and so you had your client complete a self-report questionnaire on depression at the beginning and again at the end of the therapy. Using a seven-point Likert scale, the client rated him/herself on 20 depression symptoms. If you used this scale or questionnaire, what might be the shortcomings or problems associated with this measurement system?

1.

 

2.

 

3.

 

4.

 

5.

 

At the end of this blog I’ve listed what I think are five of the most common problems with self-report outcomes measures. When you’re finished listing your five ideas, check out and compare your five ideas with my five ideas.

What are the Most Common Measurement Problems when Using Self-Report Measures in Therapy Outcomes Studies?

John’s Answers

  1. How do we know participants are giving us honest feedback about their feelings, beliefs, and response to the intervention? (Sometimes people lie, other times they deceive themselves, other times they automatically or intentionally respond in a socially desirable manner).
  2. How do we know participants are motivated to answer surveys, questionnaires, or interview questions with due diligence? (This variability in participant motivation can translate into a hasty response set or compulsive over-reflection on each item). It also results in a less than 100% response rate when surveys are administered.
  3. How do we know if participants are capable of defining or understanding what’s helpful for them? (Respondents may not have clear ways to distinguish whether what they received was helpful or they may not understand the question or they may misinterpret the question; even if they can make internal, individual distinctions of what’s helpful, how can we know how that compares with another person’s internal and individual standard for helpfulness)?
  4. How can we ever know if one person’s rating of a “5” on a 1-7 Likert (pronounced lick-ert) is ever really equivalent to someone else’s rating of a “5”? (For example, one of us has an issue with ever giving anyone or anything a perfect “7” or worthless “1” when completing seven-point Likert-type questionnaires and so his (or her) responses may not be comparable to people who don’t have such issues).
  5. Given that mood is highly variable and yet powerfully influential, how can we be sure that we’re not measuring, at least in part, something related to the respondent’s current mood, instead of current attitude or anything close to a behavioral inclination?

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Two Sample Mental Status Examination Reports

9 Comments

JSF Dance Party

This is a photo of me checking my mental status.

Generally, mental status examinations (MSEs) can have a more neurological focus or a more psychiatric focus. The following two fictional reports are samples of psychiatric-oriented MSEs. These sample reports can be helpful if you’re learning to conduct Mental Status Examinations and write MSE reports. They’re excerpted from the text, Clinical Interviewing (6th edition; 2017, John Wiley & Sons). Clinical Interviewing has a chapter devoted to the MSE, as well as chapters on suicide assessment interviewing and diagnostic interviewing (and many others chapter on other important topics). You can take a look at the book (and some darn good reviews) on Amazon: https://www.amazon.com/gp/product/1119215587/ref=dbs_a_def_rwt_bibl_vppi_i0

If you’d like to see a short video-clip MSE example, you can go to: http://www.youtube.com/watch?v=1lu50uciF5Y

Sample Mental Status Examination Reports

A good report is brief, clear, concise, and addresses the areas below:

1.  Appearance

2.  Behavior/psychomotor activity

3.  Attitude toward examiner (interviewer)

4.  Affect and mood

5.  Speech and thought

6.  Perceptual disturbances

7.  Orientation and consciousness

8.  Memory and intelligence

9.  Reliability, judgment, and insight

The following reports are provided as samples.

Mental Status Report 1

Gary Sparrow, a 48-year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was agitated and restless, frequently changing seats. He was impatient and sometimes rude in his interactions with this examiner. Mr. Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15”). His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Sparrow described grandiose delusions regarding his sexual and athletic performance. He reported auditory hallucinations (God had told him to quit his job and become a professional golfer) and was preoccupied with his athletic and sexual accomplishments. He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Mr. Sparrow was unreliable and exhibited poor judgment. Insight was absent.

Mental Status Report 2

Ms. Rosa Jackson, a 67-year-old African American female, was evaluated during routine rounds at the Cedar Springs Nursing Home. She was about 5’ tall, wore a floral print summer dress, held tight to a matching purse, and appeared approximately her stated age. Her grooming was adequate and she was cooperative with the examination. She reported her mood as “desperate” because she had recently misplaced her glasses. Her affect was characterized by intermittent anxiety, generally associated with having misplaced items or with difficulty answering the examiner’s questions. Her speech was slow, halting, and soft. She repeatedly became concerned with her personal items, clothing, and general appearance, wondering where her scarf “ran off to” and occasionally inquiring as to whether her appearance was acceptable (e.g., “Do I look okay? You know, I have lots of visitors coming by later.”). Ms. Jackson was oriented to person and place, but indicated the date as January 9, 1981 (today is July 8, 2009). She was unable to calculate serial sevens and after recalling zero of three items, became briefly anxious and concerned, stating “Oh my, I guess you pulled another one over me, didn’t you, sonny?” She quickly recovered her pleasant style, stating “And you’re such a gem for coming to visit me again.” Her proverb interpretations were concrete. Judgment, reliability, and insight were significantly impaired.

 

To receive alerts about this and other related topics like clinical interviewing and counseling and psychotherapy, you should follow this blog. Also, if you want me to come to your organization to provide a workshop or keynote on this or on a related topic, email me at john.sf@mso.umt.edu.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Uncategorized

Respecting the Client’s Perspective – Even When We Think We Know Better

Leave a comment

There are so many ways we can . . . as therapists . . . subtly (or less so) disrespect our client’s perspective. Here’s a small example from the revision of Clinical Interviewing (5th ed).

Interviewers can negatively judge or disrespect the client’s perspective in many ways. Very recently, I (John) became somewhat preoccupied about convincing a client that she wasn’t really “bipolar.” Despite my good intentions (it seemed to me that the young woman would be better off without the bipolar label), there was something useful or important for the client about holding onto her bipolar identity. Of course, as a “psychological expert” I thought it was ludicrous. I thought it obscured her many personal strengths with a label that diminished her personhood. Therefore, I tried my best to shove my opinion into her belief system. For better or worse, I was unsuccessful.

What’s clear about this example is that, despite our general expertise in mental health matters, as mental health professionals we need to work hard to respect our clients’ worldviews. In recent years practitioners from many theoretical perspectives have become more firm about the need for the expert therapist to take a back seat to the client’s personal lived experience. It’s now more important than ever for interviewers to acknowledge and embrace client expertness. This may be partly due to our increasing awareness (as mental health professionals and advocates) that clients may have very divergent views of themselves and the world.

In the end, who am I to tell my client that she is better off without a bipolar label? What if that label somehow, perhaps even in a twisted way, offers her solace. Perhaps she feels comfort in a label that helps explain her behavior to herself. Perhaps she is not ready—yet—to let go of the bipolar label. Perhaps she never will—and that may be the best outcome.

Whatever their theoretical orientation, effective interviewers respect their client’s personal expertise or perspective. We need that expertise. If the client is unwilling to collaborate with us by sharing her or his expertise and experience, we lose at least some of our potency as helpers.

 Image

John offers his brother-in-law some advice.