Tag Archives: mental health

Happiness

Advanced Mental Health for the Jackson Construction Group

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Three years ago (2019) I had the honor and privilege to be the first outside person to speak at a Jackson Construction retreat. The topic was suicide prevention. During our time at the Jackson retreat at Big Sky, Rita and I were touched by the kindness, authenticity, and engagement of the Jackson community.

On this rather frigid Montana day, I’m back with 130 Jackson employees at Fairmont Hot Springs. Once again, I’m honored and humbled to have the chance to speak. Knowing how hard it is to gain and maintain positive mental health, I deeply appreciate the chance to speak, and I hope the words and experiences I share are of use to the Jackson community.

Here is a one-page summary handout:

jackson-mh-one-pageDownload

Here are the ppts:

jackson-mh-nov-2022Download
Personal Reflections, Politics

Advocating for Children’s Mental Health

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Hi All,

This letter is primarily directed to Montana residents, although concerned out-of-state individuals may also participate or use this information to advocate for children’s mental health in your state or province.

As many of you may know, Montana State Superintendent of Schools Elsie Arntzen has recommended the elimination of the state requirement that Montana Public Schools have a required minimum number of 1 school counselor for every 400 students. Obviously, this number is already too high; the national recommendation is for 1 school counselor for every 250 students. During this time of urgent student mental health needs, we need more school counselors, not fewer.

I just wrote and sent my letter to the Montana Board of Public Education in support of retaining the school counselor to student ratio in Montana Public Schools. Please join me. Email your letter to support retaining (or increasing) the current school counselor to student ratio to: bpe@mt.gov.

The public comment period ends on November 4th, so please launch your emails soon!

If you’re not sure what to write, but you believe school counselors are important for supporting student mental health, then just write something simple like, “Please support Montana students and their mental health by retaining or increasing the current school counselor to student ratio in Montana Schools.”

If you want to write something longer, the Montana School Counselor Association has provided the following bullet points to guide public comment.

  • Keep your talking points clear and concise. Make sure to state that you are in support of keeping the school counselor to student ratio 
  • It’s ok to provide a few talking points, less may be more. If you’re not sure what to write, you could simply send a statement asking them to retain the School Counselor to Student ratio 
  • Professional and polite messages are received better
  • Provide examples as to why the ratio is important. Share your experiences within your school (maintain confidentiality), about your program, the multiple hats that you wear, any changes you have experienced over recent years, data that supports increased student needs, etc 
  • We acknowledge that there is a shortage of school counselors in Montana. Eliminating the ratio will not solve the shortage of school counselors, but could exacerbate the shortage, especially when tough budget decisions need to be made
  • Students could miss out on the proactive and responsive services our communities have come to expect from us including A) attendance and graduation rates, B) school climate and bullying prevention, C) social and emotional learning, and D) students having a professionally trained safe person to talk with

Thanks for considering this and for doing all you can to support children’s mental health and well-being.

Sincerely,

John Sommers-Flanagan

Boys and Men, Parenting, Writing

Spanking and Mental Health

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Visual from the Good Men Project. . .

Several years ago, doc students in our Counseling and Supervision program started teasing me for being preoccupied with corporal punishment in general and spanking in particular. Somehow they found my concerns about adverse mental health outcomes linked to spanking as entertaining. They were very funny about it, and so although I was somewhat puzzled, mostly I was entertained by their response, and so it was, as they say . . . all good.

Despite their occasional heckling about spanking and despite my BIG concerns about the adverse outcomes of corporal punishment, I haven’t really done any direct research on the effects of spanking. Maybe one reason I haven’t done any spanking research is because Elizabeth Gershoff of UT-Austin has already done so much amazing work. In an effort to help make her work more mainstream, today I published an article with the Good Men Project titled, “How to Discipline Children Better Without Spanking.” The article begins . . .

“As children across the country headed back to school, some students in Missouri returned to find corporal punishment, with parental approval, reinstated in their district. They joined students in 19 other states where corporal punishment is still legal in schools. At home, most American parents—an estimated 52%—agree or strongly agree that “it is sometimes necessary to discipline a child with a good, hard spanking” Parents hold this opinion despite overwhelming scientific evidence that spanking is linked to mental, emotional, and behavioral problems. In a well-known and highly regarded study of over 1,000 twins, Elizabeth Gershoff of the University of Texas at Austin found that spanking was linked to lying, stealing, fighting, vandalism, and other delinquent behaviors. Gershoff’s findings are not new.”

You can check out the full article here: https://goodmenproject.com/families/how-to-discipline-children-better-without-spanking-kpkn/

Also, a big thanks to Kristine Maloney of TVP Communications for her edits and for helping get this piece published.

Happy Tuesday!

John SF

Happiness

Evidence-Based Happiness for Belgrade Schools: Advice is Cheap, but Knowledge is Power

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Tomorrow I’ll be in Belgrade, Montana.

Back in May I received an email from a Belgrade High School AP Biology teacher asking if I could present to Belgrade teachers on mental health. The details have worked out. I’m super-excited to do this for several reasons:

  • I’m very passionate about supporting teacher mental health and well-being. For as long as I can remember (but especially during these past three years), teachers have been over-stressed, over-worked, under-paid, and under-appreciated. I even happen to have a grant proposal submitted that would give teachers access to very low-cost graduate credit on an Evidence-Based Happiness course. Happiness knowledge and mental health support for teachers is essential.
  • Education is the central “plank” on my personal political platform. IMHO, to quote myself, “The road to economic vitality, the road to environmental sustainability, the road to excellence in health care and social programs, and the road to good government always has and always will run through education.” We need excellent teachers and we need excellent public education. We need it now more than ever.
  • Belgrade is conveniently located just off I-90, a freeway that I regularly drive on my way from Missoula to Absarokee and back again.
  • And best of all, I’ll get to see the famous Nick Jones. Nick is a cool Aussie transplant, a former Carroll College basketball player, and a graduate of our M.A. program at the University of Montana. He also happens to be a school counselor at Belgrade High School.  

The ppts for tomorrow’s presentation are here:

happiness-for-belgrade-2022Download

And here’s a one-page handout/summary:

belgrade-happiness-handout-2022Download

My big theme will be that although advice is cheap, knowledge is power. We all benefit from knowing more about mental health and happiness. One of my main topics will involve information on understanding sleep. . . because we all have better mental health when we sleep well.

See you in Belgrade tomorrow!

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

Happiness Homework: Week One – University of Montana

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IMG_3098

In the friendly confines of a psychological laboratory, happiness is created rather easily. In the real world, happiness is more elusive.

Whether researchers have college students hold pens with their teeth or write down three good things or express gratitude, mood is boosted. In the real world, sometimes you have to force yourself to smile, and even still, you may not experience happiness.

You might wonder, do the small behaviors that improve mood in the lab result in sustained positive moods into the future? Martin Seligman, the contemporary psychologist most closely linked to the positive psychology movement (and author of Authentic Happiness and Flourishing) says yes. Although I’m less sure about this than Dr. Seligman, I am sure that many small behaviors over time—the sorts of behaviors that become positive habits (or positive routines)—can, for many, result in improved moods sustained over time.

Instead of assuming that everything Martin Seligman or other researchers say is true, in our University of Montana happiness class (COUN 195: The Art and Science of Happiness) we’re all about directly testing evidence-based happiness strategies. Part of the reason we’re testing these strategies is because we’re replicating nomothetic scientific findings in idiographic contexts. The true originator of positive psychology, Alfred Adler, would be happy about this. That’s because Adler believed we can never know if group scientific findings generalize to individuals, until we try them out with individuals.

In the spirit of positive psychology, and in an effort to develop and maintain healthy habits in college students, I’m giving small weekly homework assignments in the UM happiness class. Sometimes these assignments are verbatim (or nearly so) from published scientific research. Other times they’re assignments that Dan Salois (my TA) and I have created just for the class. This week’s assignments are home cooking.

I’m including these assignments on my blog so you can follow along with the class and experience different approaches to creating positive moods and psychological wellness. These assignments aren’t stand-alone miracles; they’re brief and simple behaviors purposely designed to elicit positive emotions and prompt you (and the happiness students) to reflect on the nature of positive emotions and wellness-oriented behaviors. They might work as intended, or they might not. I hope they work.

You have two assignments for this week.

Active Learning Assignment 1 – Happy Songs in Your Life

Music in general, and songs in particular, can trigger happiness, sadness, other emotions, and life memories. Sometimes our emotional responses to music are all about the music. Other times, our emotional responses are about the personal links, associations, or memories that songs trigger. For example, when I listen to “Joy to the World” by Three Dog Night, I’m transported back to positive memories I had playing 9th grade basketball. The song, “Put the Lime in the Coconut” will forever take me back to a car accident that happened with my sister in 1973. It’s not unusual for us to turn to music to help regulate our emotions or to heighten particular feelings.

For this assignment, do the following:

  1. Select a song that has triggers positive emotions for you.
  2. Listen to the song twice in a row and just let the song do its work. You can do this with a friend or by yourself. Don’t WATCH the song. If it’s a music video, shut your eyes and listen.
  3. After you’ve listened twice and let the positive feelings come, respond to the following prompts, and then upload your responses to Moodle.
    1. Write the name of the song and the musical artist (so we know the song).
    2. What emotion does the song bring up?
    3. What’s your best guess (hypothesis) for why the song brings up those particular emotions? (Share the lyrics or the links to life events that make the song emotionally important to you).
    4. Do you usually listen to that song to intentionally create a particular emotional state, or do you wait for the song to randomly pop into your life?
    5. Optional: share the song with someone and tell that person why the song triggers positive emotions for you.

Active Learning Assignment 2 – Witness Something Inspiring

Inspiring things are constantly happening in the world.

Martin Luther King Day is coming. Martin Luther King was a source of great inspiration for many. Over this coming long weekend you could watch a video recording of King’s “I have a dream” speech and feel inspired. You could also go on the internet and find something inspiring on social medial. But instead, just for fun (and for this assignment), we want you to watch for and observe something inspiring that’s happening in the real world.

The inspiring event that you notice may be small or it may be big. The key part of this assignment is that it involves intentionally watching for that which will inspire. Keep all your sensory modalities open for inspiration. Then, write Dan a short note (about 200 to 300 words) describing what you experienced. Your note should include:

  1. What it was like to intentionally pay attention to things that might inspire you.
  2. A description of what you observed.
  3. Reactions you had to the inspirational event.
  4. Anything else you want to add.

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Try these assignments for yourself (or not). If it strikes your fancy, you can post your reactions on this blog (or not).

I hope the remainder of your Martin Luther King weekend is fantastic.

Counseling and Psychotherapy Theory and Practice, Personal Reflections

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

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Coffee

Two things.

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

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

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

Clinical Interviewing, Personal Reflections, Writing

The End of Mental Illness, Part I

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Irrigation Sunrise

For years I’ve planned to write a scintillating review of the words and phrases I now, as a wise and mature adult, refuse to use. The “c-word” (expelled in 1976) and “r-word,” (out forever in 1980), and “n-word” (never used) are notable, but they’re old and tired targets that most self-respecting people in the 21th century have also banished.

BTW, I got rid of tireless in 1988 (who doesn’t get tired, especially after the birth of a child, an all-nighter, or a long day’s work?). On a related note, I got rid of countless in the early 1980s, when, while studying statistics, it became obvious to me that everything was countable, unless you got too tired or too lazy to do the counting. But, even then it didn’t make much sense to just stop counting or to lose track and suddenly declare something countless. More than anything else, the word countless struck me as lazy. I would go with the lazy explanation for countless were it not for the fact that I also eliminated lazy from my vocabulary about 15 years ago when I read about Alfred Adler’s description of people who are lazy as not lazy, but instead people whose goals are beyond their reach and consequently, they experience discouragement (and not laziness).

More recently, I’ve grown weary of “the new brain-science” (how can it be that the media continues to refer to science from the 1990s as perpetually “new” but somehow the pleats in my pants have become so “old-fashioned” that I can no longer wear them in public?). On a related note, neurocounseling and neuropsychotherapy would be on my list for potential banishment, but because they’re new terms that people invented (along with polyvagal), purely for marketing purposes, they can’t be banished, because quite conveniently, I refuse to acknowledge their existence.

All this silly ranting about words makes me sound like a crank—even to myself. But as I get older, I find that worries over sounding like a crank are, in fact, more motivating than worrisome. Indeed, I’m embracing my intellectually snooty crankiness as evidence that I’m fully addressing the crisis inherent in Erik Erikson’s seventh psychosocial developmental stage: Generativity vs. Stagnation. Yes, that’s right, instead of stagnating, I’m cranking my generativity up to a level commensurate with my age.

In contrast to all these aforementioned banished or unacknowledged words, most people (who are otherwise reasonably intelligent) continue to use the term mental illness. As a consequence, the words mental illness have now risen to the coveted #1 spot on my billboard of eliminated words.

My preoccupation with avoiding term mental illness isn’t a news flash, as my University of Montana students would happily attest. For well over a decade, I’ve been explaining to students that I don’t use the term mental illness, and warn them, with what little roguish power I can muster, that perhaps when handing in their various papers throughout the semester, they also, at least for the time being and so as to not irritate their paper-grader, ought to follow my lead.

In my social life, whenever mental illness comes up in conversation, I like to cleverly state, “I never use the term mental illness unless I’m using it to explain why I never use the term mental illness.” This repartee typically piques the interest (or ire) of my conversational cohort, usually stimulating a question like, “Why don’t you ever use the term mental illness?”

“Wow. Thanks.” I say. “I thought you’d never ask.”

Three main cornerstones form the foundation for why I’ve made a solemn oath to stop privileging the words mental illness. But first, a tangential example.

This morning, once again, I’m awake at 3:30am, despite my plan to sleep until 7:00am. I know this awakening experience very well; I also know the label for this experience is insomnia, or, more specifically, terminal insomnia, or more casually known as, early morning awakening.

After this particular early morning awakening, I briefly engaged in meditative breathing until my thoughts crowded out the meditation. Having thoughts bubble up and crowd out meditative breathing is probably a common phenomenon, because neurotic thoughts, spiritual thoughts, existential thoughts, and nearly any thoughts at all, are nearly always far more interesting than meditative breathing.

A favorite statement among existentialists is that humans are meaning makers. As with many things existential, the appropriate response is something my teenage clients have modeled for me, “Well, duh.” Channeling my ever-present inner-teen, I want to respond to my inner-existentialist with a pithy retort like, “Yeah. Of course. Humans are meaning makers. Maybe we should talk about something even more obvious, like, we all die.”

What I find fascinating about the existential claim that humans are meaning makers is that existentialists always say it with gravity and amazement, as if being a meaning-maker is a profoundly good thing.

But, like life, meaning-making is not all good, and sometimes, not good at all. As I lay in bed along with my early morning awakening, it’s nearly impossible not to begin wondering about the meaning of the dream that woke me up (there was a broken anatomical bust of Henry David Thoreau in a small ocean-side creek at Arch Cape, Oregon); even more engaging however, is the so-called lived experience of terminal insomnia, and so my middle-of-the-night dream interpretation gets pushed aside for a more pressing question. “What’s the meaning of my regular waking in the middle of the night?” My brain, without consent, calls out this question, in an all-natural and completely unhelpful lived meaning-making experience. The explanations parade through my hippocampus: Could my awakening be purely physiological? Could it be that I missed my daily caffeine curfew by 30 minutes? Perhaps this is the natural consequence. But if so, why would I awaken now, after falling asleep as my head hit the pillow and sleeping for 4½ hours, instead of having a more easily explained experience of initial insomnia.

Of course, the most common explanation for early morning awakening is neurochemically filed in my brain and easily accessible. Without effort, I recall that terminal insomnia is a common symptom of clinical depression. I’ve known that for about 40 years. Now, by 3:45am, the various competing theories have completely crowded out my breathing meditation and will settle for nothing less than my full attention.

Is my terminal insomnia simply a product of the half-life of caffeine, or a full-bladder, or primary insomnia? Or is it something even more malignant, a biological indicator of clinical depression? Do I have a mental disorder? Although that might be the case, after briefly depressing myself with the contemplation of being depressed, I also begin refuting that hypothesis. My memory of taking an online “depression” test emerges, along with my score in the mild-to-moderate depression range. I might have believed the online questionnaire result, had it not been conveniently placed on the website of a pharmaceutical company and had it not culminated in the message, “Your score indicates you may be experiencing clinical depression. Check with your doctor. Lexapro may be right for you?”

Given that I’m absolutely certain that Lexapro isn’t right for me, the pattern analysis and search for deeper meaning breaks down here. I am a meaning-maker. I woke up at 3:30am. Now it’s 4am and I’m still awake. So what? It happens. When it does, I like to get up and write. It’s productive time. My stunning meaning-making conclusion is my usual conclusion: believing that I have a mental disorder is unproductive; in contrast, believing that I’m creatively inspired to write at 3:30am is vastly preferable and consistent with what Henry David Thoreau would want me to do in this moment.

What does all this have to do with eliminating the term mental illness from the human vocabulary?

Mental Illness Lacks a Suitable Professional Definition

Mental illness is a term without a professional or scientific foundation. Even the American Psychiatric Association doesn’t use mental illness in its latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The World Health Organization doesn’t use it either. I pointed out this fun fact while attending a public journalism lecture at the University of Montana. I asked the journalist-speaker why she used “mental illness” when the American Psychiatric Association and World Health Organization don’t use it. Initially taken aback, she quickly recovered, explaining that she and other journalists were trying to put mental health problems on par with physical health problems. That’s not a bad rationale. Mostly I want mental and physical health parity too, but what I don’t want is an assumption that all mental health problems are physical illnesses and therefore require medical treatments. Besides, whenever people make up (or embrace) non-professional and scientifically unfounded terminology to further their goals, their goals begin to seem more personal and political and less pure. In the end, I don’t think it’s right to make up words to negatively classify a group of fellow humans.

A side note: The American Psychiatric Association and World Health Organization are not left-leaning bleeding hearts; they would happily use mental illness if they felt it justified. Back in 2000, the authors of the 4th edition of the Diagnostic and Statistical Manual explained their reasoning:

The term “disorder” is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as “disease” and “illness.” “Disorder” is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here.

Broadly, my first reason for refusing to use the term mental illness is that it’s not used in the definitive publications that define mental disorders. It’s too broad and consequently, unhelpful. If mental illness isn’t good enough for the American Psychiatric Association and the World Health Organization, it’s not good enough for me.

Mental Illness is Too Judgmental

When asked about diverse sexualities, Pope Francis summarized my second reason for not using the term mental illness. He famously responded, “Who am I to judge?” I love this message and believe it’s a good guide for most things in life. Who am I (or anyone) to judge (or label) someone as having a mental illness?

You might answer this question by recognizing that I’m a mental health professional and therefore empowered to judge whether someone has a mental disorder; I’m empowered to apply specific mental disorder labels (after an adequate assessment). Sure, that’s all true. But I also have a duty to be helpful; although the communication of a diagnostic label might be helpful for professional discourse, insurance reimbursement, and scientific research, I don’t see how it’s helpful to categorize a whole group of individuals as “the mentally ill.” Hippocrates founded medical science. His first rule was “Do no harm.” As fun and entertaining as diagnosing other people and myself may be, I’ve come to the conclusion that doing so is often more harmful and limiting than good.

Think about it this way. Would it be any LESS helpful for us to delete the words “the mentally ill” and replace them with “people with mental health issues?” I think not. But you can decide what fits for you.

To the extent that it’s helpful to individual clients or patients, I’m perfectly fine with, after an adequate collaborative assessment process, diagnosing individuals with specific mental disorders. I believe that process, when done well, can help. What I’m against is using a broad-brush to label a large group of fellow humans in a way that can be used for oppression and marginalization. Why not just say that everyone has mental health problems and that some people have bigger and harder to deal with mental health problems. As Carl Jung used to say, “We’re all in the soup together.”

Mental Illness Resists De-stigmatization

Mental illness and its proxies, mental disease and brain disease, are inherently, deeply, and irretrievably stigmatizing. I know several different national and local organizations that are explicitly dedicated to de-stigmatizing mental illness. My problems with this is that the words mental illness are already so saturated with negative meaning that they resist de-stigmatization. The words mental illness instantly and systematically shrink the chance for therapeutic change and positive human transmorgrification.

If you look back in time, you’ll find that mental illness was created by people who typically have a political or personal interest in labeling and placing individuals into a less-than, worse-than, not-as-good-as, category. The terminology of brain disease and brain-disabling conditions are even worse. What I’m wishing for are kinder, gentler, and less stigmatizing words to describe the natural human struggle with psychological, emotional, and behavioral problems. If you’ve got some, please send them my way. I need help in my tireless efforts to let go of my crankiness and embrace hope, especially when I wake up in the middle of the night.

 

Counseling and Psychotherapy Theory and Practice, Couple Counseling, Group therapy, Parenting

Post-Partum (now Peripartum) Depression: What you should know . . . and some resources to help you know it

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Note: This post is provided for individuals interested in learning more about post-partum or peripartum depression. It’s also a supplement for the recent Practically Perfect Parenting Podcast on “Post-Partum Depression.” You can listen to the podcast on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting/id1170841304?mt=2

stillwater-winter-view

For the first time ever on planet Earth, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the diagnosis of Peripartum Depression. Although I’m not usually a fan of labeling or big psychiatry, this is generally good news.

So, why is Peripartum Depression good news?

The truth is that many pregnant women and new moms experience depressive symptoms related to pregnancy and childbirth. These symptoms are beyond the normal and transient “baby blues.” Depressive symptoms can be anywhere from mild to severe and, combined with the rigors of pregnancy, childbirth, and parenting a newborn, these symptoms become very difficult to shake.

But the most important point is that Peripartum Depression is a problem that has been flying under the RADAR for a very long time.

Approximately 20% of pregnant women struggle with depressive symptoms. The official 12-15% estimates of post-partum (after birth) depression in women are thought to be an underestimate. What makes these numbers even worse is the fact that society views childbirth as a dramatically positive life event. This makes it all-the-more difficult for most pregnant women and new moms to speak openly about their emotional pain and misery. And, as you probably know, when people feel they shouldn’t talk about their emotional pain, it makes getting the help they deserve and recovering from depression even more difficult.

Jane Honikman, a post-partum depression survivor and founder of Postpartum Support International has three universal messages for all couples and families. She says:

  • You’re not alone
  • It’s not your fault
  • You will be well

Keep in mind that although peripartum depression is thought to have strong biological roots, the first-line treatment of choice is psychotherapy. This is because many new moms are reluctant to take antidepressant medications, but also because psychotherapy is effective in directly addressing the social and contextual factors, as well as the physiological symptoms. Additionally, as Ms. Honikman emphasizes, support groups for post-partum depression can be transformative.

Below, I’m including links and resources related to peripartum or post-partum depression.

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A very helpful informational post by Dr. Nicola Gray: http://cognitive-psychiatry.com/peripartum-depression/

Books by Jane Honikman can be found at this Amazon link. Her books include: I’m Listening: A Guide to Supporting Postpartum Families.  https://www.amazon.com/s/ref=dp_byline_sr_book_1?ie=UTF8&text=Jane+I.+Honikman&search-alias=books&field-author=Jane+I.+Honikman&sort=relevancerank

Although it’s true that peripartum depression can be debilitating, it’s also true that it can be a source of personal growth. Dr. Walker Karraa shares optimistic stories of post-partum related trauma and growth in her book:

https://www.amazon.com/Walker-Karraa/e/B00QTWH9PW/ref=dp_byline_cont_book_1

 

Counseling and Psychotherapy Theory and Practice, Tough Kids Cool Counseling

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

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

Foundations

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

1. Ethical practice
2. Multicultural sensitivity.

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

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

Evidence-Based Counselor Competence

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

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

Evidence-Based Relationship Factors

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

Congruence and Genuineness

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

The Working Alliance

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

Unconditional Positive Regard or Radical Acceptance

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

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

Empathic Understanding

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

Rupture and Repair

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

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

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

Managing Countertransference

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

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

Implementing In- and Out-of-Session Procedures

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

Progress Monitoring

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

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

Concluding Comments

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

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

References are included in the original article

Appendix

[This is added material]

A General Practice Model for Evidence-Based Mental Health Counseling

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

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

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

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

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

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

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

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

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

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

d. Congruence and Genuineness

e. Unconditional Positive Regard or Radical Acceptance

f. Empathic Understanding

g. Managing Ruptures and Engaging in Repair

h. Managing Countertransference

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

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

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

Counseling and Psychotherapy Theory and Practice, Group therapy, Personal Reflections

When Giving Gives Back

2 Comments

For several years Rita has been having first year counseling students do at least five hours of “volunteer” work with our local day treatment center for clients (or consumers) who struggle with chronic mental disorders. This year Rita is on sabbatical and so the task fell to me. To be honest, I was ambivalent about the assignment, mostly because the logistics seemed challenging. I had to arrange two separate organizational visits to the mental health center for about 15 students with different schedules before the volunteering could start and I struggled to make these happen in a timely manner. I secretly wondered if arranging this experience would be worth the hassle.

On Monday, October 29, I finally met the first group at the Day Treatment program and was emotionally transported back to the early 1980s when I was worked in a Day Treatment program and then as a recreation therapist at a 23-bed private psychiatric hospital. I listened as a staff member gave us the most unstructured orientation ever. He eventually told us that he was a “client” at the center before becoming staff. He told the students they were free to just drop in and hang out whenever. I could feel the students’ anxiety rising at the thought of just hanging out and so I asked a few questions and told a couple stories to take up time and they asked questions of their own. In an odd mix of awkwardness and genuineness and anxiety, I felt the wish to just hang out with the day treatment clients myself.   

But instead of hanging out, the reality of other responsibilities started pressing forward and I left with unresolved emotions. I decided to deal with those emotions by writing a small check to support the River House Day Treatment Member Fund. I wrote the check and sent it off.

After completing their five volunteer hours, our students are required to write a short essay about their experience. Today, I’ve spent much of my day reading these essays. They are amazingly open and appreciative of the experience. Some samples:

“I am always humbled by the willingness of others to not only be open with me and to share with me their experiences but also by the ‘sameness’ of a lot of human experiences and suffering.”

“It felt good to share in the humanness of it all- bad days, favorite things, boyfriends, girlfriends, family, and trying to find meaning even when our stories are so different.”

“The clients were not only positive and loving toward the staff members, but also towards me as a volunteer. Every client I was able to talk to complimented something about me and they were constantly complimenting each other.”

“The clients I talked with accepted me in to their community and openly shared their experiences with me. This allowed me to see the world, in a small way, through their eyes.”

Every essay has emphasized the positive environment, the loving-kindness of staff and patients, and the surprise and joy of making deeply human connections. I also received an excellent formal thank-you note from the program director (for the small donation). In it she enclosed a short note from the clients or members of the Day Treatment Center. They wrote:

Thank you so much for the monetary gift. We appreciate it so much. Your students have blessed us with their presence and we have enjoyed them. I hope that we can give the students a fresh perspective on how a special place such as River House can do good and help its members. I hope you will always feel welcome here and thank you for all you do, mentoring the students and giving gifts to us.

This letter and the feelings I get when I read “Your students have blessed us with their presence . . .” was much bigger than what I gave. That’s the same message I keep getting from my students. They went with minimal expectations, a little angst, and to clock their required hours. But instead of just completing a simple assignment, they received an experience so meaningful that many of them have are extending their volunteer work far beyond the required five hours.

This is a fabulous example of how giving can give back much more than what was originally given. This is probably what Adler meant by Gemeinschaftsguful.

Thank-you to the River House staff and members for . . . BLESSING US with YOUR presence.