Tag Archives: Psychotherapy

The Long Version of our Theoretical Orientation Test: Which Direction will our Hogwarts Theories Hat Point you?

I keep getting a steady stream of requests for the “long version” of our Theoretical Orientation Test. The TOT-Long is from our Study Guide, pictured here:

And here’s a link to the test:

When taking our TOT-Long, keep some or all of the following in the back (or front) of your mind.

  1. This questionnaire is for self-exploration; it’s not an “assessment” with established psychometrics. What that means–in the spirit of Adler–is that this so-called test is an idiographic assessment process.
  2. I’m not a big fan of counselors and psychotherapists pigeon-holing themselves into strict theoretical positions. Instead, finding a compatible theory can help you align with ways you can transform your ideas into practical ways of being and ways of working with clients. Don’t let your theoretical orientation stop you from flexibly providing clients with the services they need and want.
  3. All theory-based approaches work best from a relational foundation. If you question this basic assumption, try doing cold CBT with ambivalent or reluctant teenagers. . . or just imagining how that would go might be enough.
  4. I hope you enjoy contemplating where our theoretical “sorting hat” sends you. As with all assessments, you’re the final authority of whether the shoe (or hat) fits.

Please let me know what you think of the test and, if you’re so inclined, post your theoretical orientation as a comment here. I look forward to hearing and seeing your reactions and results.

Be well!

John SF

Happy Birthday Alfred Adler

Recently someone mistook me for an Adlerian. This got me thinking, “Maybe I am an Adlerian?” Then again, if you look at the history of counseling and psychotherapy, most of us are Adlerians. At one presentation I attended back when we attended those things, the presenters started with, “In the beginning, there was Adler.”

As a Happy Birthday tribute to Alfred Adler, below is an excerpt from our Adlerian theories chapter. There’s much more, of course, like, for example, what Adlerian theory would have to say about the Super Bowl.

Happy Birthday Dr. Adler.

Historical Context

Freud and Adler met in 1902. According to Mosak and Maniacci (1999), Adler published a strong defense of Freud’s Interpretation of Dreams, and consequently Freud invited Adler over “on a Wednesday evening” for a discussion of psychological issues. “The Wednesday Night Meetings, as they became known, led to the development of the Psychoanalytic Society” (p. 3).

Adler was his own man with his own ideas before he met Freud. Prior to their meeting he’d published his first book, Healthbook for the Tailor’s Trade (Adler, 1898). In contrast to Freud, much of Adler’s medical practice was with the working poor. Early in his career, he worked extensively with tailors and circus performers.

In February 1911, Adler did the unthinkable (Bankart, 1997). As president of Vienna’s Psychoanalytic Society, he read a highly controversial paper, “The Masculine Protest,” at the group’s monthly meeting. It was at odds with Freudian theory. Instead of focusing on biological and psychological factors and their influence on excessively masculine behaviors in males and females, Adler emphasized culture and socialization (Carlson & Englar-Carlson, 2017). He claimed that women occupied a less privileged social and political position because of social coercion, not physical inferiority. Further, he noted that some women who reacted to this cultural situation by choosing to dress and act like men were suffering, not from penis envy, but from a social-psychological condition he referred to as the masculine protest. The masculine protest involved overvaluing masculinity to the point where it drove men and boys to give up and become passive or to engage in excessive aggressive behavior. In extreme cases, males who suffered from the masculine protest began dressing and acting like girls or women.

The Vienna Psychoanalytic Society members’ response to Adler was dramatic. Bankart (1997) described the scene:

After Adler’s address, the members of the society were in an uproar. There were pointed heckling and shouted abuse. Some were even threatening to come to blows. And then, almost majestically, Freud rose from his seat. He surveyed the room with his penetrating eyes. He told them there was no reason to brawl in the streets like uncivilized hooligans. The choice was simple. Either he or Dr. Adler would remain to guide the future of psychoanalysis. The choice was the members’ to make. He trusted them to do the right thing. (p. 130)

Freud likely anticipated the outcome. The group voted for Freud to lead them. Adler left the building quietly, joined by the Society’s vice president, William Stekel, and five other members. They moved their meeting to a local café and established the Society for Free Psychoanalytic Research. The Society soon changed its name to the Society for Individual Psychology. This group believed that social, familial, and cultural forces are dominant in shaping human behavior. Bankart (1997) summarized their perspective: “Their response to human problems was characteristically ethical and practical—an orientation that stood in dramatic contrast to the biological and theoretical focus of psychoanalysis” (p. 130).

Adler’s break from Freud gives an initial glimpse into his theoretical approach. Adler identified with common people. He was a feminist. These leanings reflect the influences of his upbringing and marriage. They reveal his compassion for the sick, oppressed, and downtrodden. Before examining Adlerian theoretical principles, let’s note what he had to say about gender politics well over 90 years ago:

All our institutions, our traditional attitudes, our laws, our morals, our customs, give evidence of the fact that they are determined and maintained by privileged males for the glory of male domination. (Adler, 1927, p. 123)

Raissa Epstein may have had a few discussions with her husband, exerting substantial influence on his thinking (Santiago-Valles, 2009).

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You can take a peek at our Theories text on Amazon: https://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1119473314/ref=sr_1_1?crid=LIAVFMJLE5TD&dchild=1&keywords=sommers-flanagan&qid=1612716309&s=books&sprefix=sommers-%2Caps%2C205&sr=1-1

Becoming a Reality Therapist: The Reality Therapy Lab

Let’s say you want to practice reality therapy. Maybe more than any other approach, you’ll need to use reality therapy on yourself to become a reality therapist. Here’s what I mean.

You could consider channeling a little William Glasser, because he’s the developer of reality therapy. Then again, you might not want to channel Glasser, because, as Robert Wubbolding has written, to become a reality therapist, “You need not imitate the style of anyone else.”

The point is that you get to do the choosing . . . and a great start is to choose to use Wubbolding’s summary of the delivery system of reality therapy. Wubbolding used the letters, WDEP to summarize reality therapy, and these letters also happen to appear on Wubbolding’s car license plate. If you’re getting the feeling that Wubbolding is committed to reality therapy principles, you would be absolutely right. WDEP stands for Wants, Doing, Evaluation, and Planning. The following four questions capture WDEP:

What do you want?

What are you doing?

Is what you’re doing working? [Evaluation]

Should you make a new plan?

Before enacting reality therapy, you’ll need to adopt a positive, engaged, courteous, enthusiastic, counselor demeanor. You also need to be ready to use your excellent active listening skills. Avoiding toxic relational strategies like arguing, blaming, and criticizing is crucial. Think of yourself as a mentor or coach, and then practice the following strategies to see if they fit for you.

Begin by helping your client (or role-play partner) identify what he/she/they want. You could use any of the following questions:

If we could work on something that feels important to you, what would that be?

What do you want from our meeting today?

This is a big question, but I’m going to ask it anyway: What do you want from life?

If we have a good session and accomplish something that feels good to you, what will we have accomplished?

After you’ve gotten a sense of what your client is wants, you can move onto an inquiry about how your client is currently trying to get those wants. Questions like the following might help:

How are you currently trying to get what you want?

What have you tried?

I imagine you’ve tried various strategies for getting what you want to happen in your life. Tell me about all those things you’ve tried and how they’ve worked.

You can see from this last question, that asking about what clients are doing naturally leads to what Wubbolding considers to be the most important step in reality therapy: Evaluation. Wubbolding hypothesizes that many clients don’t get taught how to self-evaluate and/or may not have much practice at self-evaluation. He uses questions like the following to prompt client self-evaluation.

Is what you’re doing helping or hurting?

Is want you want realistic and attainable?

Does your self-talk help or hinder you in your efforts to get what you want?

Wubbolding has many additional questions about how to help clients self-evaluate in his book, Reality Therapy for the 21st Century. Check it out.

This brings us to the final question: Should you make a new plan? I think one of the most important insights that reality therapy brings to the counseling table is its emphasis on active and smart planning. Although SMART plans originated in the business world, Wubbolding has an extensive guide for how to help clients make effective plans. In my experiences doing counseling and psychotherapy, I’ve been astonished at how often clients go off in search of goals with either no plans or bad plans. For Wubbolding, client plans should be: Simple, Attainable, Measurable, Immediate, Involved, Controlled, Committed, and Continuous (Wubbolding’s acronym for planning is SAMI2C3). For more information on how to create SAMI2C3 plans, see Wubbolding’s book or the chapter in our Counseling and Psychotherapy Theories in Context and Practice textbook.

All planning that happens in counseling should be collaborative planning. Your job, as you engage in this important planning step, is to come alongside clients, brainstorm small tweaks or big changes in how clients might attain their goals, and to give them constructive feedback about whether their plan is a smart plan while providing encouragement and collaboratively evaluating the plan’s effectiveness. I have no doubt that reality therapy can be effective, partly because the first three reality therapy questions are so central to human functioning, but also because a good plan is a beautiful thing.

Note: the content of this blog is primarily adapted from the section that Robert Wubbolding wrote for our theories textbook.

Essential Information about Counseling and Psychotherapy Theories

A good summary is a beautiful thing. But summaries are always unfair and limited representations of that which is bigger. Nevertheless, below, I’ve tried to summarize the primary listening focus and the primary change mechanisms for each of 13 theoretical orientations included in our textbook, Counseling and Psychotherapy Theories in Context and Practice (John Wiley & Sons, 2018). In addition, yesterday I filmed myself using a memory-palace strategy while describing all 13 perspectives below. You can read the summary below and/or watch me try to pull off this 15 minute theories overview on YouTube: https://youtu.be/VJFK6cCHCU8

TheoryWhat to Listen For. . .Change Mechanisms
Psychoanalytic PsychodynamicOld maladaptive intrapersonal conflicts and repetitive, unconscious, and dysfunctional interpersonal patterns.Make unconscious conscious, catharsis, and working through new intra- and interpersonal dynamics.
AdlerianBasic mistakes imbedded in the style of life, including excess self-interest and inferiority/superiority.Awareness, insight, and encouragement (courage) to face the tasks of life.
ExistentialAnxiety over and avoidance of core existential life dynamics like death, isolation, meaninglessness, and freedom.Feedback and confrontation to help clients gain awareness and face life’s ultimate existential demands.
Person-CenteredEmotional distress, incongruence (discrepancies between real and ideal selves), and conditions of worth.A relationship characterized by congruence, unconditional positive regard, and empathic understanding.
GestaltUnfinished emotional and behavioral baggage from the past that blocks awareness or disturbs self-other boundaries.Guidance on using here-and-now experiments to deal with unfinished emotional and behavioral experiences.
BehavioralDisturbing emotions (e.g., anxiety), maladaptive behavior patterns, and environmental contingencies.New learning or re-learning via operant, classical, and social processes.
CBTDisturbing emotions (e.g., anxiety, anger), maladaptive thinking, maladaptive behaviors, and triggers/contingenciesCollaborative and empirical tasks that modify maladaptive or distorted cognitive information processing.
Choice Theory/Reality TherapyWhat clients want, what they’re doing, whether that’s working, and planning.Commit to and enact adaptive plans that are aligned with quality world goals.
FeministWhere is the client experiencing anger or dissatisfaction due to gender-based limits or oppressive situations?Relational connection and empowerment to actively seek personal goals and mutually empathic emotional relationships.
ConstructiveWhere clients are stuck and how existing client strengths, exceptions, and solutions can fuel change.Re-shaping, reframing, and reconsolidating old narratives and problem-based patterns through solutions and sparkling moments.
Family SystemsFamily dynamics, transactions, hierarchy, roles, and boundaries that contribute to personal or systemic dysfunction.Shift family dynamics and transactions via in-session and outside session assignments.
MulticulturalWhere is the client experiencing distress due to limiting or oppressive socio-political factors?Cultural acceptance, empowerment, and culturally-based rituals.
IntegrativeWhat are the client’s unique problems, strengths, and consistent ways of thinking, acting, and feeling?Match a therapeutic process to the client’s unique problems and strengths.

My Cache of Unprofessional Counseling and Psychotherapy Theories Videos

In a surprising turn of events, this semester, I’ve decided to make a series of unprofessional theories videos to accompany my counseling and psychotherapy theories course (and text). When I say surprising, I mean surprising in that I’m surprised about feeling open to spontaneously video recording myself and making it available via YouTube. Could it be that as I grow older, I care less about how I look and sound, and care more about showing myself openly to others as an imperfect being who’s just trying to offer up something that might be educational? Alternatively, maybe I just caught the narcissistically-leaning, reality television, constantly-make-videos-of-myself, YouTube, Instagram, Facebook, Tiktok, virus that’s infecting so many people. We may never know.

And I say unprofessional because I’m filming these all by myself, not using a script, and making side comments and using props that might involve embarrassing myself as I talk about counseling and psychotherapy theories. One form of these unprofessional videos includes me doing “dramatic readings” and commentary from the works of Freud, Adler, and other original theories thinkers and writers. Although I intended these readings to be dramatic, I can see how they also might just be dull.

With my explanations and caveats out of the way, here are the offerings, thus far, for this semester.

Week 1 – An Intro to Counseling and Psychotherapy Theories

Hypnosis for Warts: A Story – https://youtu.be/9FR4PyTcsKw

Psychotherapy Math – https://youtu.be/ZqMW0SNekY0

Week 2 – Psychoanalytic Approaches

Freud Dramatic Reading – https://youtu.be/L-fkveRk7B0

Week 3 – Individual Psychology and Adlerian Therapy

Adler Dramatic Reading, Take 1 – https://youtu.be/_sVysgm1UiY

Adler Dramatic Reading, Take 2 – https://youtu.be/xCQd6i_CWAI

Week 4 – Existential Theory and Therapy . . . coming soon!

Although this post focuses on my unprofessional videos, that doesn’t mean I’ve completely stopped behaving professionally. For example, recently, I was a guest on the podcast, “A New Angle” hosted by Justin Angle and Bryce Ward (both of the University of Montana College of Business). In this podcast, we talk about COVID, suicide in Montana, happiness, and why the College of Business supports the teaching “Essential” interpersonal and psychological skills. It’s a pretty cool (and professional) podcast, even if I do say so myself. You can find “A New Angle” on Apple Podcasts at:

https://podcasts.apple.com/us/podcast/i-i-happiness-with-john-sommers-flanagan/id1336642173

Or at: anewanglepodcast.com

I hope you’re all having a great run-up to the weekend.

Suicide Assessment Should be Therapeutic Assessment

This morning (or afternoon, depending on your time zone), I’ll be participating on a panel discussion titled, “Treating and Preventing Suicide.” Although the event has reached maximum capacity, the link for more information is here: https://catalog.pesi.com/sq/pn_001386_essentialstreatingpreventingsuicide_panel_aca-139059?fbclid=IwAR2QYfDxVFjdnnDHV1JwKUYh54JqKzvhpneB98FF-yNrk5fcbFfPMdtyuWs

As a resource to complement the panel discussion, I’m posting some information on suicide assessment. Below is the opening from the suicide assessment chapter in our forthcoming book with the American Counseling Association. We emphasize that suicide assessment isn’t purely data collection. Instead, professionals need to simultaneously keep their eye on how to be therapeutic. Here’s the excerpt:

Suicide assessment integrates science and art. Assessment science helps practitioners determine what information is most important during a clinical interview and how to best obtain reliable and valid assessment data (Sommers-Flanagan et al., 2020; Wygant et al., 2020). The art of assessment includes how and when to ask questions, relational methods for offering empathy, and how clinicians can partner with clients to explore symptoms and strengths in ways that facilitate trust and stimulate honesty (Ganzini et al., 2013). Because suicide is a painful and provocative topic, advanced assessment skills are essential.

When clients or students experience suicidality, exposure to an assessment process can feel threatening. As a consequence, we believe counselors should embrace principles of therapeutic assessment (Fischer, 1970, 1985). Therapeutic assessment originated in the late 1960’s, when Constance Fischer began practicing and publishing about a radical new assessment approach. Unlike traditional objective and unilateral approaches to assessment, Fischer (1969, 1970) began viewing clients as “co-evaluators.” Stephen Finn has extended Fischer’s ideas; the approach is now called therapeutic assessment (Finn et al., 2012).

Therapeutic assessment principles are consistent with the professional counseling paradigm (Capuzzi & Stauffer, 2016); they include collaboration, compassion, openness, honesty, and a commitment to valuing clients as ultimate experts on their lived experiences. Although information gathering remains important, relationship connection during assessment interviews takes priority. Every assessment finding needs to be validated and understood within each client’s unique personal context. Collaboration is the cornerstone; assessments are done with clients, not on clients (Martin, 2020; Sommers-Flanagan & Sommers-Flanagan, 2017). As Flemons and Gralnik (2013) wrote, when conducting suicide assessments, “Our goal is not to remain objectively removed but, rather, to become empathically connected” (p. 6).

There are several “therapeutic” strategies for suicide assessment interviewing. Jobes’s (2016) book is a great resources, as is Freedenthal’s (2018). You can also check out our Clinical Interviewing suicide assessment chapter, or read this free blog post on using a mood scaling method: https://johnsommersflanagan.com/2018/05/25/suicide-assessment-mood-scaling-with-a-suicide-floor/

Obviously, there’s not enough time and space to go into great depth on suicide assessment in a little blog like this. And so, if you looking for depth, check out the video series I did with Victor Yalom and Psychotherapy.net. You can even watch a short demonstration video clip: https://www.psychotherapy.net/video/suicidal-clients-series

I wish you all the best as you face the challenge of engaging with and treating clients who are suicidal with the therapeutic respect they deserve.

Guidelines for Giving and Receiving Feedback

Feedback 2

Giving and receiving feedback is a huge topic. In this blog post the focus is on giving and receiving feedback in classroom settings or in counseling/psychotherapy supervision. The following guidelines are far from perfect, but they offer ideas that instructors and students can use to structure the feedback giving and receiving process. Check them out, and feel free to improve on what’s here.

Before you do anything, remember that feedback can feel threatening. Hearing about how we sound and what we look like is pretty much a trigger for self-consciousness and vulnerability. Sometimes, when we look in the mirror, we don’t like what we see, and so obviously, when someone else holds up a mirror, the feedback we experience may be . . . uncomfortable. . . to say the least. To help everyone feel a bit safer, the following can be helpful:

  • Acknowledge that feedback is scary.
  • Emphasize that feedback is essential to counseling skill development.
  • Share the feedback process you’ll be using
  • Make recommendations and give examples of what kind of feedback is most useful.

Acknowledge that Feedback is Scary: You can talk about mirrors (see above), or about how unpleasant it is for most people to hear their own voices or see their own images, or tell a story of difficult and helpful feedback. I encourage you to find your own way to acknowledge that feedback triggers vulnerability.

Feedback is Essential: Encourage students to lean into their vulnerability and be open to feedback—but don’t pressure them. Explain: “The reason you’re in a counseling class is to improve your skills. Though hard to hear, constructive feedback is useful for skill development. Don’t think of it as criticism, but as an opportunity to learn from mistakes and improve your counseling skills.” What’s important is to norm the value of giving and getting feedback.

Share the Process You’ll be Using: Before starting a role play or in-class practice scenario, describe the guidelines you’ll be using for giving and receiving feedback (and then generate additional rules from students in the class). Here are some guidelines I’ve used:

  • Everyone who volunteers (or does a demonstration or is being observed) gets appreciation. Saying, “Thanks for volunteering” is essential. I like it when my classes established a norm where whoever does the role-playing or volunteers gets a round of applause.
  • After being appreciated, the role-player starts the process with a self-evaluation. You might say something like, “After every role play or presentation, the first thing we’ll do is have the person or people who were role-playing share their own thoughts about what they did well and what they think they didn’t do so well.”
  • After the volunteer self-evaluates, they’re asked whether they’d like feedback from others. If they say no, then no feedback should be given. Occasionally students will feel so vulnerable about a performance that they don’t want feedback. We need to accept their preference for no feedback and also encourage them to solicit and accept feedback at some later point in time.

Giving Useful Feedback: Feedback should be specific, concrete, and focused on things that can be modified. For example, you can offer a positive or non-facilitative behavioral observation (e.g., “I noticed you leaned back and crossed your arms when the client started talking about their sexuality.”). After making an observation, the feedback giver can offer a hypothesis (e.g., “Your client might interpret you leaning back and crossing your arms as judgmental”). The feedback giver can also offer an alternative (“Instead, you might want to lean forward and focus on some of your excellent nonverbal listening skills.”). BTW: General and positive comments (e.g., “Good job!”) are pleasant and encouraging, but should be used in combination with more specific feedback; it’s important to know what was good about your job.

Constructive or corrective feedback shouldn’t focus so much on what was done poorly, but emphasize what could be done to perform the skill correctly. Constructive or corrective feedback might sound like this: “I noticed you asked several closed questions that seemed to slow down the counseling process. Closed questions aren’t bad questions, but sometimes it’s easier to keep clients talking about important content if you replace your closed questions with open questions or with a paraphrase. Let’s try that.”

Other examples: Instead of saying, “Your body was stiff as a board,” try saying, “I think you’d be more effective if you relaxed your arms and shoulders more.” Or you could take some of the evaluation out of the comment by just noticing or observing, rather than judging, “I noticed you said the word, ‘Gotcha’ several times.” You can also ask what else they might say instead, “To vary how you’re responding to your client, what might you say instead of ‘Gotcha’?”

General negative comments such as “That was poorly done.” should be avoided. To be constructive, provide feedback that’s specific, concrete, and holds out the potential for positive change. Also, feedback should never be uniformly negative. Everyone engages in counseling behaviors that are more or less facilitative. If you happen to be the type who easily sees what’s wrong, but you have trouble offering praise, impose the following rule on yourself: If you can’t offer positive feedback, don’t offer any at all. Another alternative is to use the sandwich feedback technique when appropriate (i.e., say something positive, say something constructive, then say another positive thing).

IMHO, significant constructive feedback is the responsibility of the instructor and should be given during a private, individual supervision session. The general rule of: “Give positive feedback in public and constructive feedback in private” can be useful.

Finally, students should be reminded of the disappointing fact that no one performs perfectly, including the teacher or professor. Also, when you do demonstrations, be sure to model the process by doing a self-evaluation (including things you might have done better), and then asking students for observations and feedback.

 

 

Our Upcoming ACA Book on Suicide Assessment and Treatment Planning: Sneak Peek #2

River Rising 2020

Hey,

I hope you’re all okay and social distancing and mask wearing and hand-washing and staying healthy and well.

Today I’m working on Chapter 6 – The Cognitive Dimension in Suicide Assessment and Treatment Planning (or something like that).

As always, please share your feedback. Or, if you have no feedback and like what you read, just share the post, because, as we all know, acts of kindness grow happiness.

Here’s an excerpt on working with hopelessness.

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Working with Hopelessness as it Emerges During Sessions

Clinicians can address hopelessness in two ways. First, when hopelessness emerges in the here-and-now, clinicians need to be ready to respond empathically and effectively. Client hopelessness manifests in different ways. Sometimes hopelessness statements have depressing content (e.g., “I’ve never been happy and I’ll never be happy”); other times hopelessness statements include irritability (e.g., “Counseling has never worked for me. I hate this charade. It won’t help.”). Either way, in-session hopelessness statements can be provocative and can trigger unhelpful responses from counselors. Preparing yourself to respond therapeutically is important.

Second, hopelessness among clients who are depressed and suicidal manifests as an ongoing, long-term cognitive style. As with most cognitive styles, hopelessness is linked to cognitive distortions wherein clients have difficulty (a) recalling past successes, (b) noticing signs of hope in the immediate moment, or (c) believing that their emotional state or life situation could ever improve. We address in-session hopelessness next and hopelessness as a longer-term cognitive distortion in the subsequent section.

Expressing Empathy

Imagine you’re working with a new client. You want to be encouraging, and so you make a statement about the potential for counseling to be helpful. Consider the following exchange:

Counselor: After getting to know you a bit, and hearing what’s been happening in your life, I want to share with you that I think counseling can help.

Client: I know you mean well, but this is a waste of time. My life sucks and I want to end it. Popping in to chat with you once a week won’t change that.

When clients make hopelessness statements, you may feel tempted to counter with a rational rebuttal. After all, if client hopelessness represents a pervasive depression-related cognitive distortion or impairment, then it makes sense to offer a contrasting rational and accurate way of thinking. Although instant rational rebuttals worked for Albert Ellis, for most counselors, immediately disputing your clients’ global, internal, and hopeless cognitions will create resistance. Instead, you should return to an empathic response.

Counselor: I hear you saying that, right now, you don’t think counseling can help. You feel completely hopeless, like your life sucks and is never going to change and you just want it to end.

Staying empathic—even though you know that later you’ll be targeting your client’s hopeless distorted thinking—requires accurately reflecting your clients’ hopelessness. You may even use a tiny bit of motivational interviewing amplification (i.e., using the phrase, “never going to change” could function as an amplification). What’s important to remember about this strategy is that mirroring your clients’ hopelessness will likely stand in stark contrast to what your clients have been experiencing in their lives. In most situations, if your clients have spoken about their depression and suicidality with friends or family, they will have heard responses that include reassurance or emotional minimization (e.g., “I’m sure things will get better” or “You’re a wonderful person, you shouldn’t think about suicide” or “Let’s talk about all the blessings you have in your life”).

Remaining steadily empathic with clients as they express hopelessness is an intentionally different and courageous way to do counseling. Staying empathic means that you’re sticking with your clients in their despair. You’re not running from it; you’re not minimizing it; you’re not brushing it aside as insignificant. Instead, you’re resonating with your clients’ terribly depressive and suicidal cognitive and emotional experiences.

If you choose the courageous and empathic approach to counseling, you need to do so with the conscious intention of coming alongside your clients in their misery. Following the empathic path can take you deep into depressive ways of thinking and emoting. This can affect you personally; you may begin adopting your clients’ impaired depressive thinking and then feel depressed yourself. Part of being conscious and intentional means you’re choosing to temporarily step alongside and into your clients’ depressive mindset. You need to be clear with yourself: “I’m stepping into the pit of depression with my client, but even as I’m doing this, my intention is to initiate Socratic questioning or cognitive restructuring or collaborative problem-solving when the time is right.”

The next question is: “How long do you need to stay alongside your client in the depressive mindset?” The answer varies. Sometimes, just as soon as you step alongside your clients’ hopelessness, they will rally and say something like, “It’s not like I’m completely hopeless” or “Sometimes I feel a little hope here or there.” When your client makes a small, positive statement, your next job is to gently nurture the statement with a reflection (e.g., “I hear you saying that once in a while, a bit of hope comes into your mind”), and then explore (and possibly grow) the positive statement with a solution-focused question designed to facilitate elaboration of the exceptional thought (e.g., “What was different about a time when you were feeling hopeful?”). Then, for as long as you can manage, you should follow Murphy’s (2015) solution-focused model for working with client exceptions. This includes:

  1. Elicit exceptions. (You can do this be asking questions like “What was different. . .” and by using the motivational interviewing techniques of coming alongside or amplified reflection.)
  2. Elaborate exceptions. (You do this with questions like “What’s usually happening when you feel a bit of hope peek through the dark clouds?”)
  3. Expand exceptions. (You move exceptions to new contexts and try to increase frequency, “What might help you feel hope just a tiny bit more?”)
  4. Evaluate exceptions. (You do this by collaboratively monitoring the utility or positivity of the exception, “If you were able to create reminders for being hopeful to use throughout the day, would you find that a plus or minus in your life?”)
  5. Empowering exceptions. (You do this by giving clients credit for their exceptions and asking them what they did to make the exceptions happen, “How did you manage to get yourself to think a few positive thoughts when you were in that conflict with your supervisor?”).

In other cases, you’ll need to stick with your clients’ misery and hopelessness longer. However, because this is a strength-based model and because the evidence suggests that clients who are suicidal sometimes need their counselor to explicitly lead them toward positive solutions, you will need to watch for opportunities to turn or nudge or push your clients away from abject hopelessness.

 

Free Video Links for Online Teaching

JSF Travel

This past week I’ve been grateful for the many professionals and organizations (including my publisher, John Wiley & Sons) who are providing free guidance and materials to help with the transition from face-to-face teaching to online instruction. In an effort to contribute back in a small way, I’m posting 10 counseling- and psychotherapy-related videos that can be integrated into online teaching. These videos are free and posted on my YouTube channel. The links are all below with a brief description of the video content.

Some of these videos are rough cuts and all of them are far from perfect demonstrations; that’s partly the point. Although many of the videos show reasonably good counseling skills and interesting assessment processes and therapeutic interventions, none of the videos are scripted, and so there’s plenty of room for review, analysis, critique, and discussion. You can show them as efforts to do CBT, SFBT, Motivational Interviewing, administration of a mental status examination, etc., and prompt students to describe how they would do these sessions even better.

These videos are meant to stimulate learning. In an ideal world, I would include a list of discussion questions, but I’ll leave that to you. If you like, please feel free to use these videos for educational purposes. Here’s the annotated list with video links:

  1. Counseling demonstrations with a 12-year-old.
    1. Opening a counseling session: https://www.youtube.com/watch?v=rHHrMC8t6vY
    2. The three-step emotional change trick: https://www.youtube.com/watch?v=ITWhMYANC5c
    3. John SF demonstrates the What’s Good About You? informal assessment technique: https://www.youtube.com/watch?v=MUhmLQUg_g8
    4. Closing a session: https://www.youtube.com/watch?v=GpuH80tf2jM
  2. Demo of assessment for anger management with a solution-focused spin with a 20-year-old client: https://www.youtube.com/watch?v=noE2wMMNLY4
  3. Demo of motivational interviewing with a 30-year-old client: https://www.youtube.com/watch?v=rtN7kEk0Sv4
  4. Demo of the affect bridge technique with an 18-year-old: https://www.youtube.com/watch?v=fEtiGuc914E
  5. Demo of CBT for social anxiety with a graduate student: https://www.youtube.com/watch?v=jfVeeGJHFjA
  6. Demo of an MSE with a 20-year-old: https://www.youtube.com/watch?v=adwOxj1o7po
  7. A lecture vignette of a demonstration of psychoanalytic ego defense mechanisms: https://studio.youtube.com/video/E818UlgHMXY/edit
  8. The University of Montana Department of Counseling does a spoof video of The Office: https://www.youtube.com/watch?v=eM8-I8_1CqQ

Good luck with the transition to online teaching and stay healthy!

John S-F

Integrating Multicultural Sensitivity into CBT

Woman Statue

A question and brief discussion on Twitter about integrating multicultural competence into CBT inspired me to look back and see what the heck we wrote for that section in our theories text. In the Twitter discussion, we agreed that Pam Hays’s work on CBT and multicultural content is good.

Here’s what I found in our theories text. Obviously it’s a short section and limited, but there are a few interesting points and a citation or two.

Cultural and Diversity Considerations in CBT

CBT focuses on symptoms as manifest within individuals. This position can be (and is) sometimes viewed as disregarding important culture, gender, and sexual diversity issues. For most cognitive-behavioral therapists, culture, gender, and sexuality aren’t primary factors that drive successful outcomes.

This position is a two-edged sword. In the featured case (in Chapter 8), Richard is a white male living a life squarely in the middle of the dominant culture. The therapist was committed to Richard’s well-being. If the client had been an Asian Indian or a bisexual or a woman experiencing domestic abuse the cognitive-behavioral therapist would have been equally committed to the client’s well-being. This is the positive side of CBT being less diversity-oriented.

The negative side is that CBT can be viewed and experienced as blaming clients for their symptoms, when the symptoms may be a function of diversity bias. D. Dobson and K. S. Dobson (2009) articulated the potential for clients to experience blame,

By virtue of looking for distorted thoughts, cognitive-behavioral therapists are more likely than other therapists to find them. Furthermore, some clients do react to the terms distorted, irrational, or dysfunctional thinking. We have heard clients say something to the effect—” Not only do I feel bad, but now I’ve learned that my thoughts are all wrong.” (p. 252)

Awareness of the possibility of client blaming is crucial. For example, what if Richard were a Black American male? And what if his therapist noticed that Richard’s thought record included numerous personalization examples? If so, instead of concluding that Richard is displaying oversensitivity and paranoid cognitions, his therapist should explore the possibility of microaggressions in Richard’s daily life.

The term microaggression was coined by Chester Pierce (1978). Microaggressions were originally defined as “the everyday subtle and often automatic ‘put-downs’ and insults directed toward Black Americans” but now this is expanded so they “can be expressed toward any marginalized group in our society” (Sue, 2010, p. 5).

Microaggressions are typically unconscious. For example, we had a female client come to us in great distress because her vocational instructor had told her “You’re pretty strong for a girl.” Although the vocational instructor defended his “compliment,” the young woman clearly didn’t experience the statement as a compliment. In this circumstance if a therapist is insensitive to culture and gender issues, the young woman might feel blamed for having irrational thoughts and overreactive behaviors. Sue (2010) recommends that mental health professionals exercise vigilance to address microaggression issues inside and outside of counseling. One way in which cognitive behavioral practitioners have addressed the potential for committing microaggressions against sexually diverse clients is by using LGBTQ affirmative CBT (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015).

Returning to racial/cultural microaggressions, let’s briefly pretend that Richard is a 6′7′′ Black American male. In his thought record he notes:

Situation: Walking into the local grocery store. Young female makes eye contact with me and then quickly turns around and goes back and locks her car.

Thoughts: She thinks I’m going to steal her car.

Emotions: Anger.

Behavior: I act rude toward her and toward other white people I see in the store.

If the Black American version of Richard has a therapist who looks at this thought record and then talks with Richard about the distorted thinking style of mind-reading (“Richard, you didn’t really know what she was thinking, did you?”) this therapist is showing cultural insensitivity and will likely be fired by Richard. This is an example of one of the many growing edges CBT should address with respect to women and minority clients.

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As always, your reactions to this content are welcome.