Tag Archives: Psychotherapy

Clinical Interviewing, Suicide Assessment and Intervention

R-I-P-SC-I-P: An Acronym for Remembering the Essential Components of a Suicide Assessment Interview

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This post is part 1 of a follow up to requests I’ve gotten following the MUS Suicide Prevention Summit in Bozeman. A number of people asked: What’s R-I-P-SC-I-P and how do I get more information about it? The answer is that it’s just an acronym to help practitioners recall key areas to cover in a comprehensive suicide assessment interview. But because I made it up in honor of Robert Wubbolding while doing a workshop in Cincinnati (he’s created several acronyms for Choice Theory and Reality Therapy), I’m pretty much the only source.

The following is a pre-published excerpt from the Suicide Assessment chapter in the forthcoming 6th edition of Clinical Interviewing. It includes some general information, a summary of R-I-P-SC-I-P, and some guidance on how to talk with clients about suicide ideation. Much more of this is in the whole chapter, but I can’t post it here.

Suicide Assessment Interviewing

A comprehensive and collaborative suicide assessment interview is the professional gold standard for assessing suicide risk. Suicide assessment scales and instruments can be a valuable supplement—but not a substitute—for suicide assessment interviewing (see Putting It in Practice 10.1).

A comprehensive suicide assessment interview includes the following components:

  • Gathering information about suicide risk and protective factors: This should be done in a manner that emphasizes your desire to understand the client and not as a checklist to estimate risk
  • Asking directly about possible suicidal thoughts
  • Asking directly about possible suicide plans
  • Gathering information about client self-control and agitation
  • Gathering information about client suicide intent and reasons to live
  • Consultation with one or more professionals
  • Implementation of one or more suicide interventions, including, at the very least, collaborative work on developing an individualized safety plan
  • Detailed documentation of your assessment and decision-making process (Table 10.3 includes an acronym to help you recall the components of a comprehensive suicide assessment interview)

Table 10.3: RIP SCIP – A Suicide Assessment Acronym

R = Risk and Protective Factors
I = Suicide Ideation
P = Suicide Plan
SC = Client Self-Control and Agitation
I = Suicide Intent and Reasons for Living
P = Safety Planning

These assessment domains or dimensions form the acronym R-I-P-SC-I-P (pronounced RIP SKIP).

Exploring Suicide Ideation

Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.

Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can seem rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.

The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.

Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:

  • Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
  • I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
  • I want my clients to share their suicidal thoughts.
  • If my clients share their suicidal thoughts and plans, I can handle it!

If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.

Asking Directly about Suicide Ideation

Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.

Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.

A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:

Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)

A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.

Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask: “When was the last time when you had thoughts about suicide?” Gentle assumption can make it easier for clients to disclose suicide ideation.

Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.

1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)

2. Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)

3. What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)

4. What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)

5. What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)

6. For you, what would be a normal mood rating on a normal day? (Clients define their normal.)

7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)

8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.

Responding to Suicide Ideation

Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?

First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:

Given the stress you’re experiencing, it’s not unusual that you think about suicide sometimes. It sounds like things have been really hard lately.

This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.

As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.

  • Frequency: How often do you find yourself thinking about suicide?
  • Triggers: What seems to trigger your suicidal thoughts? What gets them started?
  • Duration: How long do these thoughts stay with you once they start?
  • Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?

As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.

Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.

Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.

On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.

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

Parallel Process in Clinical Supervision

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This short case example from the forthcoming 6th edition of Clinical Interviewing is a small tribute to all the great supervisors I had over the years.

Case Example 7.2:

Intermittent Unconditional Positive Regard and Parallel Process

Abby is a 26-year-old graduate student. She identifies as a White Heterosexual female. After an initial clinical interview with Jorge, a 35-year-old who identifies as a male heterosexual Latino, she meets with her supervisor. During the meeting she expresses frustration about her judgmental feelings toward Jorge. She tells her supervisor that Jorge sees everyone as against him. He’s extremely angry at his ex-wife and he’s returning to college following his divorce and believes his poor grades are due to racial discrimination. Abby tells her supervisor that she just doesn’t get Jorge. She thinks she should refer him instead of having a second session.

Abby’s supervisor listens empathically and is accepting of Abby’s concerns and frustrations. The supervisor shares a brief story of a case where she had difficulty experiencing positive regard toward a client who had a disability. Then, she asks Abby to put herself in Jorge’s shoes and imagine what it would be like to return to college as a 35-year-old Latino man. She has Abby imagine what might be “under” Jorge’s palpable anger toward his ex-wife. The supervisor also tells Abby, “When you have a client who views everyone as against him, it’s all the more important for you to make an authentic effort to be with him.” At the end of supervision Abby agrees to meet with Jorge for a second session and to try to explore and understand his perspectives on a deeper level. During their next supervision session, Abby reports great progress at experiencing intermittent unconditional positive regard for Jorge and is enthused about working with him in the future.

One way to enhance your ability to experience unconditional positive regard is to have a supervisor who accepts your frustrations and intermittent judgmental-ness. If the issues that arise in therapy are similar (or parallel) to the issues that arise in supervision, it’s referred to as parallel process (Searles, 1955). This is one reason why when you get a dose of unconditional positive regard in supervision, it may help you pass it on to your client.

 

John Rap

Clinical Interviewing

Can Mental Health Professionals Predict Violent Behavior in Schools and Agencies?

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Not surprisingly, violence has been on my mind lately. And so when I reached the Violence Risk Assessment section of the Clinical Interviewing text revision, I decided to cut and paste it here. It doesn’t immediately answer the question of whether mental health professionals can predict violence and so if you’re impatient and prefer to stop reading now, the answer to that question is, more or less, “No.”

Assessment and Prediction of Violence and Dangerousness

During an assessment interview, John had the following exchange with a 16-year-old client.

John: I hear you’ve been pretty mad at your shop teacher.

Client: I totally hate Mr. Smith. He’s a jerk. He puts us down just to make us feel bad. He deserves to be punished.

John: You sound a little pissed off at him.

Client: We get along fine some days.

John: What do you mean when you say he “deserves to be punished”?

Client: I believe in revenge. Really, I feel sorry for him. But if I kill him, I’ll be doing him a favor. It would end his miserable life and stop him from making other people feel like shit.

John: So you’ve thought about killing him?

Client: I’ve thought about walking up behind him and slitting his throat.

John: How often have you thought about that?

Client: Just about every day. Whenever he talks shit in class.

John: And exactly what images go through your mind?

Client: I just slip up behind him while he’s talking with Cassie [fellow student] and then slit his throat with a welding rod. Then I see blood gushing out of his neck and Cassie starts screaming. But the world will be a better place without his sorry ass tormenting everybody.

John: Then what happens?

Client: Then I guess they’ll just take me away, but things will be better.

John: Where will they take you?

Client: To jail. But I’ll get sympathy because everyone knows what a dick he is.

During an initial interview or ongoing therapy, clients may describe aggressive thoughts and images. Some clients, as in the preceding example, will be concise about their thoughts, feelings, and images. Others will be less clear. Still others will be evasive and will avoid telling you anything about violent thoughts or intentions.

Assessing for violence potential is similar to assessing for suicide potential; it’s a stressful responsibility and predicting violence is extremely difficult. However, similar to suicide assessment, we still have a legal and ethical responsibility to conduct violence or dangerousness assessments that meet professional standards.

Over the years, there have been arguments about how to most accurately predict violence (Hilton, Harris, & Rice, 2006). Essentially, there are three perspectives.

1. Some researchers contend that actuarial prediction based on specific, predetermined statistical risk factors is consistently the most accurate procedure (Quinsey, Harris, Rice, & Cormier, 2006).

2. Some clinicians believe that because actuarial variables are dimensional and interactive with individual and situational characteristics, prediction based on the clinician’s experience and intuition is most accurate (Cooke, 2012).

3. Others take a moderate position, believing that combining actuarial and clinical approaches is best (Campbell, French, & Gendreau, 2009).

Researchers have consistently reported that actuarial approaches to violence prediction are more accurate than clinical judgment (Monahan, 2013). However, actuarial violence prediction is not without its flaws (Szmukler, 2012; Tardiff & Hughes, 2011).

Narrowing in on Particular Violent Behaviors

Researchers who investigate actuarial assessment protocols have reported that different violent behaviors are associated with unique predictor variables. Below, we provide three examples of violence predictors for three different specific violent behaviors or populations. The goal is to sensitize you to different violent behavior patterns.

Fire-setting. Fire-setting is a particular dangerous behavior that may or may not be associated with interpersonal violence. Nonetheless, depending on your work setting and the clinical population you serve, you may find yourself in a situation in which you need to decide whether to warn a family or potential victim about possible fire-setting behavior.

Mackay and colleagues (2006) reported on specific behaviors included on a fire-setting prediction assessment. They identified the following variables—in decreasing order—as predictive of fire setting:

  •  Younger age at the time of the first fire-setting behavior.
  • A higher total number of fire-setting offenses.
  • Lower IQ.
  • Additional criminal activities associated with the index (initial) fire.
  • An offender acting alone in setting the initial fire.
  • A lower offender’s aggression score. (Interestingly, offenders with higher aggression scores were more likely to be violent, but less likely to set fires.)

We focus first on fire setting here because fire-setting predictors illustrate a general violence-prediction principle. Past violence is a reasonably good predictor of future violence only with regard to specific past and future violence. For example, future fire-setting potential is best predicted by past fire-setting behavior. Similarly, future physical aggression is best predicted by past physical aggression. But a history of physical aggression is not a good predictor of fire setting.

Homicide Among Young Men. Loeber and associates (2005) conducted a large-scale landmark study of homicide among young men living in Pittsburgh. This study is notable because it was both prospective and comprehensive; the authors tracked 63 risk factor (predictor) variables in 1,517 inner-city youth. Obviously, even this large-scale study is limited in scope, and technically the results cannot be generalized beyond inner-city Pittsburgh youth. Nevertheless, the outcome data are interesting and lend insight into risk factors that might contribute to homicidal violence in other populations.
Results from the study indicated that violent offenders scored significantly higher than nonviolent offenders on 49 of 63 risk factors across domains associated with child, family, school, and demographic risk factors. The range and nature of these predictors were daunting. The authors reported:

. . . predictors included factors evident early in life, such as the mother’s cigarette or alcohol use during pregnancy, onset of delinquency prior to 10 years of age, physical aggression, cruelty, and callous/unemotional behavior. In addition, cognitive factors, such as having low expectations of being caught, predicted violence. Poor and unstable child-rearing factors contributed to the prediction of violence, including two or more caretaker changes prior to 10 years of age, physical punishment, poor supervision, and poor communication. Undesirable or delinquent peer behavior, based either on parent report or self-report, predicted violence. Poor school performance and truancy were also among the predictors of violence. Finally, demographic factors indicative of family disadvantage (low family SES, welfare, teenage motherhood) and residence in a disadvantaged neighborhood also predicted violence. Among the proximal correlates associated with violence were weapon carrying, weapon use, gang membership, drug selling, and persistent drug use. (p. 1084)

Homicidal violence was best predicted by a subset of general violence predictor variables. Specifically, homicide was predicted by “the presence or absence of nine significant risk factors:

• Screening risk score
• Positive attitude to substance use
• Conduct disorder
• Carrying a weapon
• Gang fight
• Selling hard drugs
• Peer delinquency
• Being held back in school
• Family on welfare (p. 1086).

In particular, boys who had at least four of these nine risk factors were 14 times more likely to have a future homicide conviction than violent offenders with a risk score less than four.

Violence and schizophrenia. In and of itself, a diagnosis of schizophrenia doesn’t confer increased violence risk. Instead, research indicates there are specific symptoms—when seen among individuals diagnosed with schizophrenia—associated with increased risk. These symptoms include severe manifestations of:

  • Hallucinations
  • Delusions
  • Excitement
  • Thinking disturbances. (Fresán, Apiquian, & Nicolini, 2006)

This research suggests that clinicians should be especially concerned about violence when clients diagnosed with schizophrenia have acute increases in the intensity and frequency of their psychotic symptoms.

Research versus Practice

For a short guide to predicting violence, see a previous post: https://johnsommersflanagan.com/2013/02/25/guidelines-for-violence-risk-assessment/

IMG_2473

 

Counseling and Psychotherapy Theory and Practice

Constructivism vs. Social Constructionism: What’s the Difference?

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This is an excerpt from the beginning of Chapter 11 of Counseling and Psychotherapy Theories in Context and Practice (3rd  ed., John Wiley & Sons, 2018). Despite the heavily intellectual content and use of the traditional sex binary, I hope you’ll find this way of defining these two different post-modern perspectives helpful, and I hope you get the joke at the end.

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The best way to begin a chapter on constructive theory and therapy is with a story.

Once upon a time a man and a woman met in the forest. Both being academic philosophers well-steeped in epistemology, they approached each another warily. The woman spoke first, asking, “Can you see me?”

The man responded quickly: “I don’t know,” he said. “I have a plethora of neurons firing in my occipital lobe and, yes, I perceive an image of a another person and I can see your mouth was moving precisely as I was experiencing auditory input. Therefore, although I’m not completely certain you exist out there in reality—and I’m not completely certain there even is a reality—I can say without a doubt that you exist … at least within the physiology of my mind.”

Silence followed.

Then, the man spoke again,

“Can you hear me?” he asked.

The woman responded: “I’m not completely certain about the nature of hearing and the auditory process, but I can say that in this lived moment of my experience I’m in a conversation with you and because my knowledge and my reality is based on interactive discourse, whether you really exist or not is less important than the fact that I find myself, in this moment, discovering more about myself, the nature of the world, and my knowledge of all things.”

There are two main branches of constructive theory. These branches are similar in that both perspectives hold firmly to the postmodern idea that knowledge and reality are subjective.

What is Constructivism and What is Social Constructionism?

Constructivism, as represented by the man in the forest, includes people who believe knowledge and reality are constructed within individuals. In contrast, social constructionism, as represented by the woman in the forest, includes people who believe knowledge and reality are constructed through discourse or conversation. Constructivists focus on what’s happening within the minds or brains of individuals; social constructionists focus on what’s happening between people as they join together to create realities. Guterman (2006) described these two perspectives:

Although both constructivism and social constructionism endorse a subjective view of knowledge, the former emphasizes individuals’ biological and cognitive processes, whereas the latter places knowledge in the domain of social interchange. (p. 13)

In this chapter, just as you might avoid traditional “constructed” gender binaries, we de-emphasize distinctions between constructivist and social constructionist perspectives. Mostly, we lump them together as constructive theories and therapies and emphasize the intriguing intervention strategies developed within these paradigms. This may upset staunch constructivists or radical social constructionists, but we take this risk with full confidence in our personal safety—because most constructive types are nonviolent, strongly preferring to think, write, and engage in intellectual discussion. Therefore, within our own socially or individually constructed realities, we’ve concluded that we’re in no danger of bodily harm from angry constructive theorists or therapists.

Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Multicultural, Therapy with Adolescents

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

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This is a rough preview of a section from the 6th edition Clinical Interviewing. As always, your thoughts and feedback are welcome.

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

Research on how to practice with culturally diverse youth is especially sparse. To make matters more complex, youth culture is already substantially different from adult culture. This means that if you’re different from young clients on traditional minority variables, you’ll be experiencing a double dose of the cultural divide. These complications led one writer to title an article “A knot in the gut” to describe the palpable transference and countertransference that can arise when working with race, ethnicity, and social class in adolescents (Levy-Warren, 2014).

To help reduce the size of the knot in your gut, we’ve developed a simple research- and common-sense list to guide your work with culturally diverse youth (Bhola & Kapur, 2013; Norton, 2011; Shirk, Karver, & Brown, 2011; Villalba, 2007):

1. Use the interpersonal skills (e.g., empathy, genuineness, respect) that are known to work well with adult minority group members. Keep in mind that interpersonal respect is an especially salient driver in smoothing out intercultural relationships.

2. Find ways to show genuine interest in your young clients, while also focusing on their assets or strengths.

3. Treat the meeting, greeting, and first session with freshness and eagerness. There’s evidence that young clients find less experienced therapists easier to form an alliance with.

4. Use a genuine and clear purpose statement. It should capture your “raison d’etre” (your reason for being in the room). We like a purpose statement that’s direct and has intrinsic limits built in. For example: “My goal is to help you achieve your goals . . . just as long as your goals are legal and healthy.” One nice thing about this purpose statement is that sometimes young clients think the “legal and healthy” limitations are funny.

5. Don’t use a standardized approach to always talking with youth about your cultural differences. Instead, wait for an opening that naturally springs up from your interactions. For example, when a teen says something like, “I don’t think you get what I’m saying” it’s a natural opening to talk about how you probably don’t get what the youth is saying. Then you can discuss some of your differences as well as you’re desire to understand as much as you can. For example: “You’re right. I probably don’t get you very well. It’s obvious that I’m way older than you and I’m not a Native American. But I’d like to understand you better and I hope you’ll be willing to help me understand you better. Then, in the end, you can tell me how much I get you and how much I don’t get you.”

6. Provide clear explanations of your procedure and rationale and then linger on those explanations as needed. If young clients don’t understand the point of what you’re doing, they’re less likely to engage.

7. Be patient with your clients; research with young clients and diverse clients indicate that alliance-building (and trust) takes extra time and won’t necessarily happen during an initial session

8. Be patient with yourself; it may take time for you to feel empathy for young clients who engage in behaviors outside your comfort zone (e.g., cutting)

I hope these ideas can help you make connections with youth from other cultures. The BIG summary is to BE GENUINE and BE RESPECTFUL. Nearly everything else flows from there.

Counseling and Psychotherapy Theory and Practice

Supplementary Counseling and Psychotherapy Theories Readings

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Over the past four years I’ve written over 40 blog posts linked to teaching and learning the theory and practice of counseling and psychotherapy. While procrastinating on another project, I decided to organize these blog posts by topic. If you follow the links below, they’ll take you to blog posts relevant to specific theories. Included in some of these are a few links to short (and free) theories-based video examples. If you teach a theories course, you could select some of these links to assign students outside readings or you could peruse them yourself to stimulate a few lecture ideas.

Please note that if you use our Counseling and Psychotherapy Theories in Context and Practice textbook, there’s a bit of redundancy with the textbook’s content. However, if you don’t use the text, the material will be new to you and your students.

Chapter 1 – Opening and Overview

A Plan for Maximizing Positive Counseling and Psychotherapy Outcomes: https://johnsommersflanagan.com/2014/09/07/a-plan-for-maximizing-positive-counseling-and-psychotherapy-outcomes/

Teaching Counseling and Psychotherapy Theories: Reflections on Week 1: https://johnsommersflanagan.com/2012/08/29/teaching-counseling-and-psychotherapy-theories-reflections-on-week-1/

Reformulating Clinical Depression: The Social-Psycho-Bio Model: https://johnsommersflanagan.com/2013/09/03/reformulating-clinical-depression-the-social-psycho-bio-model/

Chapter 2 – Psychoanalytic Approaches

Attachment-Informed Psychotherapy: https://johnsommersflanagan.com/2015/08/12/attachment-informed-psychotherapy/

Chapter 3 – Adlerian Approaches: Individual Psychology

The Three-Step Emotional Change Trick: https://johnsommersflanagan.com/2012/09/23/the-three-step-emotional-change-trick/

A Parenting Homework Assignment on Natural and Logical Consequences: https://johnsommersflanagan.com/2011/11/30/a-parenting-homework-assignment-on-natural-and-logical-consequences/

More Than Praise — Other Ways Parents Can Be Positive With Their Children: https://johnsommersflanagan.com/2012/08/16/more-than-praise-other-ways-parents-can-be-positive-with-their-children/

Chapter 4 – Existential Approaches

Reflections on Listening to Irvin Yalom at the ACA Conference: https://johnsommersflanagan.com/2012/03/25/reflections-on-listening-to-irvin-yalom-at-the-aca-conference/

A Short Existential Case Example from Counseling and Psychotherapy Theories . . .: https://johnsommersflanagan.com/2015/08/25/a-short-existential-case-example-from-counseling-and-psychotherapy-theories/

Chapter 5 – Person-Centered Approaches

Reflections on Magic: https://johnsommersflanagan.com/2011/11/28/reflections-on-magic/

Listening as Meditation on Psychotherapy.net: https://johnsommersflanagan.com/2014/02/25/listening-as-meditation-on-psychotherapy-net/

An Interview with Natalie Rogers (Daughter of Carl Rogers) about Person-Centered Therapy: https://johnsommersflanagan.com/2015/08/04/an-interview-with-natalie-rogers-daughter-of-carl-rogers-about-person-centered-therapy/

Why Therapists Should Never Say, “I know how you feel”: https://johnsommersflanagan.com/2013/05/30/why-therapists-should-never-say-i-know-how-you-feel/

Carl Rogers and Brain-Science do an Empathy Smackdown in Chapter 3: https://johnsommersflanagan.com/2015/07/09/carl-rogers-and-brain-science-do-an-empathy-smackdown-in-chapter-3/

Chapter 6 – Gestalt Approaches

Go Go Gestalt: The Theories Video Shoot, Part I: https://johnsommersflanagan.com/2012/04/24/go-go-gestalt-the-theories-video-shoot-part-i-2/

Chapter 7 – Behavioral Approaches

A Black Friday Tribute to Mary Cover Jones and her Evidence-Based Cookies: https://johnsommersflanagan.com/2011/11/25/a-black-friday-tribute-to-mary-cover-jones-and-her-evidence-based-cookies/

Behavioral Activation Therapy: Let’s Just Skip the Cognitions: https://johnsommersflanagan.com/2014/06/30/behavioral-activation-therapy-lets-just-skip-the-cognitions/

Imaginal or In Vivo Exposure and Desensitization: https://johnsommersflanagan.com/2012/05/19/imaginal-or-in-vivo-exposure-and-desensitization-2/

A New Look at Time-Out for Kids and Parents: https://johnsommersflanagan.com/2012/08/04/a-new-look-at-time-out-for-kids-and-parents/

Information on Using Time-Out — Part II: https://johnsommersflanagan.com/2012/08/05/information-on-using-time-out-part-ii/

Talking with Parents about Positive Reinforcement: https://johnsommersflanagan.com/2014/09/06/talking-with-parents-about-positive-reinforcement/

Backward Behavior Modification: https://johnsommersflanagan.com/2012/12/02/backward-behavior-modification/

Chapter 8 – Cognitive-Behavioral Approaches

Positive Thinking is Not (Necessarily) Rational Thinking: https://johnsommersflanagan.com/2011/12/06/positive-thinking-is-not-necessarily-rational-thinking/

How to Use the Six Column CBT Technique: https://johnsommersflanagan.com/2014/02/18/how-to-use-the-six-column-cbt-technique/

A Quick Look at the Collaborative Cognitive Therapy Process: https://johnsommersflanagan.com/2012/09/30/a-quick-look-at-the-collaborative-cognitive-therapy-process/

Tomorrow’s Election and Confirmation Bias: https://johnsommersflanagan.com/2012/11/05/tomorrows-election-and-confirmation-bias/

Confirmation Bias on My Way to Spearfish, South Dakota: https://johnsommersflanagan.com/2014/04/30/confirmation-bias-on-my-way-to-spearfish-south-dakota/

Chapter 9 – Choice Theory and Reality Therapy

The Seven Magic Words for Parents: https://johnsommersflanagan.com/2012/12/23/the-seven-magic-words-for-parents/

Give Information and then Back-Off: A Choice Theory Parenting Assignment: https://johnsommersflanagan.com/2012/07/09/give-information-and-then-back-off-a-choice-theory-parenting-assignment/

How Parents Can Use Problem-Solving Power: https://johnsommersflanagan.com/2012/10/23/how-parents-can-use-problem-solving-power/

Chapter 10 – Feminist Approaches

Opening Thoughts on Feminism: https://johnsommersflanagan.com/2012/04/03/opening-thoughts-on-feminism-3/

The Girl Code by Ashley Marallo: https://johnsommersflanagan.com/2012/12/03/the-girl-code-by-ashley-marallo/

A Guest Essay on the Girl Code and Feminism: https://johnsommersflanagan.com/2014/12/07/a-guest-essay-on-the-girl-code-and-feminism/

Feminist Culture in Music: https://johnsommersflanagan.com/2013/11/18/feminist-culture-in-music/

Chapter 11 – Constructive (Solution-Based and Narrative) Approaches

Is Solution-Focused Therapy as Powerfully Effective as Solution-Focused Therapists Would Have Us Believe?: https://johnsommersflanagan.com/2012/07/01/is-solution-focused-therapy-as-powerfully-effective-as-solution-focused-therapists-would-have-us-believe-2/

Secrets of the Miracle Question: https://johnsommersflanagan.com/2015/03/04/secrets-of-the-miracle-question/

The Love Reframe: https://johnsommersflanagan.com/2013/04/07/the-love-reframe/

Chapter 12 – Family Systems Approaches

None posted on this topic. Obviously, I need help here.

Chapter 13 – Multicultural Approaches

Four Good Ideas about Multicultural Counseling and Psychotherapy—In Honor of Martin Luther King, Jr.: https://johnsommersflanagan.com/2012/01/16/four-good-ideas-about-multicultural-counseling-and-psychotherapy-in-honor-of-martin-luther-king-jr/

Good Ideas about Multicultural Counseling and Psychotherapy – Part II: https://johnsommersflanagan.com/2012/01/22/good-ideas-about-multicultural-counseling-and-psychotherapy-part-ii/

Cultural Adaptations in the DSM-5: Insert Foot in Mouth Here: https://johnsommersflanagan.com/2014/07/08/cultural-adaptations-in-the-dsm-5-insert-foot-in-mouth-here/

Psychic Communications . . . and Cultural Differences in Mental Status: https://johnsommersflanagan.com/2013/01/02/psychic-communications-and-cultural-differences-in-mental-status/

A White Male Psychologist Reflects on White Privilege: https://johnsommersflanagan.com/2012/09/14/a-white-male-psychologist-reflects-on-white-privilege/

Chapter 14 – Integrative Approaches

None on this chapter either.

Counseling and Psychotherapy Theory and Practice

A Short Existential Case Example from Counseling and Psychotherapy Theories . . .

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Each chapter in Counseling and Psychotherapy Theories in Context and Practice includes at least two case vignettes. These vignettes are brief, but designed to articulate how clinicians can use specific theories to formulate cases and engage in therapeutic interactions. The following case is excerpted from the Existential Theory and Therapy chapter.

This post is part of a series of free posts available to professors and students in counseling and psychology who are teaching and learning about theories of counseling and psychotherapy. It, as well as the recommended video clip at the end, can be used for discussion purposes and/or to supplement course content.

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Vignette II: Using Confrontation and Visualization to Increase Personal Responsibility and Explore Deeper Feelings

In this case, a Native American counselor-in-training is working with an 18-year-old Latina female. The client has agreed to attend counseling to work on her anger and disruptive behaviors within a residential vocational training setting. Her behaviors are progressively costing her freedom at the residential setting and contributing to the possibility of her being sent home. The client says she would like to stay in the program and complete her training, but her behaviors seem to say otherwise.

Client: Yeah, I got in trouble again yesterday. I was just walking on the grass and some “ho” told me to get on the sidewalk so I flipped her off and staff saw. So I got a ticket. That’s so bogus.

Counselor: You sound like you’re not happy about getting in trouble, but you also think the ticket was stupid.

Client: It was stupid. I was just being who I am. All the women in my family are like this. We just don’t take shit.

Counselor: We’ve talked about this before. You just don’t take shit.

Client: Right.

Counselor: Can I be straight with you right now? Can I give you a little shit?

Client: Yeah, I guess. In here it’s different.

Counselor: On the one hand you tell me and everybody that you want to stay here and graduate. On the other hand, you’re not even willing to follow the rules and walk on the sidewalk instead of the grass. What do you make of that?

Client: Like I’ve been saying, I do my own thing and don’t follow anyone’s orders.

Counselor: But you want to finish your vocational training. What is it for you to walk on the sidewalk? That’s not taking any shit. All you’re doing is giving yourself trouble.

Client: I know I get myself trouble. That’s why I need help. I do want to stay here.

Counselor: What would it be like for you then . . . to just walk on the sidewalk and follow the rules?

Client: That’s weak brown-nosing bullshit.

Counselor: Then will you explore that with me? Are you strong enough to look very hard right now with me at what this being weak shit is all about?

Client: Yeah. I’m strong enough. What do you want me to do?

Counselor: Okay then. Let’s really get serious about this. Relax in your chair and imagine yourself walking on the grass and someone asks you to get on the sidewalk and then you just see yourself smiling and saying, “Oh yeah, sure.” And then you see yourself apologize. You say, “Sorry about that. My bad. You’re right. Thanks.” What does that bring up for you.

Client: Goddamn it! It just makes me feel like shit. Like I’m f-ing weak. I hate that.

In this counseling scenario the client is conceptualized as using expansive and angry behaviors to compensate for inner feelings of weakness and vulnerability. The counselor uses the client’s language to gently confront the discrepancy between what the client wants and her behaviors. As you can see from the preceding dialogue, this confrontation (and the counselor’s use of an interpersonal challenge) gets the client to look seriously at what her discrepant behavior is all about. This cooperation wouldn’t be possible without the earlier development of a therapy alliance . . . an alliance that seemed deepened by the fact that the client saw the counselor as another Brown Woman. After the confrontation and cooperation, the counselor shifts into a visualization activity designed to focus and vivify the client’s feelings. This process enabled the young Latina woman to begin understanding in greater depth why cooperating with rules triggered intense feelings of weakness. In addition, the client was able to begin articulating the meaning of feeling “weak” and how that meaning permeated and impacted her life.

To check out a 4+ minute existential counseling video clip go to: https://www.youtube.com/watch?v=jiirtIKcIeM

This clip is taken from our Counseling and Psychotherapy Theories 2 DVD set. The 2 DVD set is available through Psychotherapy.net: http://www.psychotherapy.net/video/counseling-psychotherapy-theories and Amazon: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1118402537/ref=asap_bc?ie=UTF8

Clinical Interviewing

Women’s Cleavage and the Man’s Package in Professional Counseling and Psychotherapy

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In 2013, for the first time in the history of counseling and psychotherapy textbook writing (at least our history), Rita and I included a section heading titled “Straight Talk about Cleavage” in the 5th edition of Clinical Interviewing. This section was inspired by comments posted on the Counselor Education and Supervision Listserv (aka CESNET). Now, we’re working on the revision for the 6th edition (affectionately referred to as CI6). For CI6 we solicited reactions from students, professional counselors, and professional psychologists. Not surprisingly, we received some fun, stimulating, and challenging responses.

For your reading pleasure, here’s the first draft of the revised section on cleavage. You’ll notice that it begins with a section on “Self-Presentation.” That’s because the cleavage and related content is a subsection of the self-presentation section.

This is a draft . . . and so please feel free to message me (or post) your comments and reactions. Thanks for reading.

Self-Presentation

You are your own primary instrument for a successful interview. Your appearance and the manner in which you present yourself to clients are important components of professional clinical interviewing.

Grooming and Attire
Choosing the right professional clothing can be difficult. Some students ignore the issue; others obsess about selecting just the right outfit. The question of how to dress may reflect a larger developmental issue: How seriously do you take yourself as a professional? Is it time to take off the ripped jeans, remove the nose ring, cover the tattoo, or lose the spike heels? Is it time to don the dreaded three-piece suit or carefully pressed skirt and come out to do battle with mature reality, as your parents may have suggested? Don’t worry. We recognize the preceding sentences are probably pushing your fashion-freedom buttons. We’re not really interested in telling you how you should dress or adorn your body. Our point is self-awareness. If you’re working in rural Texas your tattoo and nose ring will have a different effect than if you’re an intern in urban Chicago. Even if you ignore your physical self-presentation, your clients—and your supervisor—probably won’t.

We knew a student whose distinctive style included closely cropped, multicolored hair; large earrings; and an odd assortment of scarves, vests, sweaters, runner’s tights, and sandals. Imagine his effect on, say, a middle-aged dairy farmer referred to the clinic for depression, or a mother-son dyad having trouble with discipline, or the local mayor and his wife. No matter what effect you imagined, the point is that there’s likely to be an effect. Clothing, body art, and jewelry are not neutral; they’re intended to communicate, and they do (Human & Biesanz, 2012). An unusual fashion statement can be overcome, but it may use up time and energy better devoted to other issues (see Putting It in Practice 2.3). As a therapist your goals is to present yourself in a way that creates positive first impressions. This includes dress and grooming that foster rapport, trust, and credibility.

In one research study (albeit dated), Hubble and Gelso (1978) reported that clients experienced less anxiety and more positive feelings toward psychotherapists who were dressed in a manner that was slightly more formal than the client’s usual attire. The take home message from this research, along with common sense, is that it’s better to err slightly on the conservative side, at least until you’re certain that dressing more casually won’t have an adverse effect on your particular client population. As a professional colleague of ours tells her students, “A client should not walk away from your session thinking too much about what you wore” (S. Patrick, personal communication, June 27, 2015).

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

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

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

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

Minding the Body for Males
It’s inappropriate to stop our discussion about sexuality and sexual perceptions without addressing the other end of the sexuality and gender continuum. To start, we should emphasize that, to a large extent, our cautions about cleavage aren’t really about breasts; instead, these are comments about cultural messages pertaining to sex and sexuality and how clients are likely to perceive and react to seeing too much of certain portions of their therapist’s skin. Back in Freud’s day and setting, viewing women’s ankles was reportedly rather titillating. This observation begs the question: “Is it possible for individuals who identify as being on the male end of the sexual identity continuum to dress in ways that might be described as titillating?” When we tried to experiment with this in a group counseling class, mostly the feedback was that the males were being “gross” and “disgusting.”

Despite the fact that our students reacted negatively to the idea of males exposing their skin, we should note that throughout the history of time, therapists who engaged in inappropriate, unethical, and illegal sexual behavior with clients have been disproportionately male. This leads us to conclude that our cautions about females showing cleavage is at the least ironic and at most sexist. Consistent with feminist theory, when men sexualize a woman’s body, it shouldn’t be viewed as the woman’s fault.

These issues are obviously laden with cultural stereotypes, norms, and expectations. In an effort to balance our coverage (no pun intended) of this topic, we went online and asked professionals and colleagues to give us feedback about the “Straight Talk about Cleavage” section. A summary of this feedback is included below.

Feedback on Cleavage
A warning to male therapists: Male therapists need to watch their own flirtatious behavior. They might consult with a female therapist friend to check out anything that might be questionable. I know, most males don’t have cleavage issues, but they sometimes do make provocative comments, such as, “You know, you should take that lovely sexuality of yours and use it to your advantage.” I’m not making this up. Also, they might want to rein in, “You are so pretty. I’ll bet this gets the guys going.” I’m not making this up either. (J. Hocker, personal communication, June 27, 2015).

Extending the conversation to male therapists: I do think part of the unfairness in professional attire for women vs. men is that men’s work wear is simply “easier.” But a woman doesn’t have to dress like a man in order to be taken seriously as a professional. Curiously, I do find that the conversation regarding appearance needs to take place with men; for example, male students who want to wear flip flops, large jewelry, or “muscle” shirts. We also talk about whether or not to wear things that reveal tattoos, hair styles, and so on – so I think men are now as much a part of the conversation as women (S. Patrick, personal communication, June 27, 2015)

A Message from a Licensed School Counselor: I know professionals in counseling and teaching who exhibit poor hygiene, dress, and might toss some cleavage out from time to time. Students do notice, and it’s not cool. In my profession I want students to see me as casual, clean, and someone they’re drawn to for a good ear and safe space. I don’t want them to see cleavage ever. It’s a distraction. Cleavage is sexy and draws attention no matter what. I’m not drawn to women sexually but I’m super distracted by cleav! I can’t imagine how a person attracted to females would react! I find that when I’m not at work there are dates and social functions available that allow me to find my sexy self, but that self doesn’t fit into the school counseling profession. Yes, women should be able to wear what they want, but the reality is if you sport cleav you’ll receive notice by everyone and there’s a time and place to celebrate our cleav; work may not be the place. (M. Robbins, personal communication, June 30, 2015)

The Man’s “Package”: I noticed there’s no mention of a man’s “package” or the open seating posture many men use that gives quite a clear view of any crotch bulging that may be had. I think this deserves to be discussed as well, and not just as an afterthought – it is at least as important as cleavage to the imagination and distraction.

One thing that seems to go on in common discourse is an acceptance of the idea that men are more sexually focused than women. This is problematic on a couple fronts, I think. Although research shows some increased arousal for men from visual stimuli compared to visual stimuli for women BOTH men and women have been shown to be aroused by visual stimuli. BOTH women and men want sex for physical pleasure, not just as a relational tool. The difference is in degree to which these things are acknowledged by each sex, perhaps, but I haven’t seen compelling evidence that there’s actually a difference in the degree to which men and women can be sexually distracted by physical bodies. It’s neither then men’s nor women’s job, then, to “protect” clients from that distraction more than another (C. Yoshimura, personal communication).

Monitoring Flirtatious Behavior
Behavior standards for mental health professionals are high. This is partly true for being a professional of any type. However, mental health professional standards for dress and flirtation are higher than most other professions. If you think about the setting and process, the high standards make sense. Personal disclosures and conversations that happen during clinical interviews and other mental health-related encounters naturally involve non-sexual intimacy. It follows that deep emotional disclosures and exchanges between client and therapist might arouse feelings related to sexual intimacy in clients and/or therapists. It’s perfectly natural for non-sexual intimacy to sometimes trigger feelings of sexual intimacy . . . and so maintaining professional boundaries in this area is essential. All ethical codes that pertain to professional counselors, psychologists, and social workers prohibit sexual contact between therapist and client. The bottom line is that it’s your responsibility, as a mental health professional or student therapist, to closely monitor your attire and behavior to make certain you’re not directly or indirectly communicating flirtatiously with your clients.

Counseling and Psychotherapy Theory and Practice

Attachment-Informed Psychotherapy

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

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

Attachment-Informed Psychotherapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

John and Nora

Counseling and Psychotherapy Theory and Practice

An Interview with Natalie Rogers (Daughter of Carl Rogers) about Person-Centered Therapy

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Of all the counseling and psychotherapy approaches out there, person-centered therapy might be the most quickly dismissed of them all. I’ve had therapists watch or listen to a PCT demonstration and then make dismissive comments like: “Oh yeah. That was just basic listening skills. I know all about that.”

It’s usually hard for me to figure out how to best respond to that sort of statement. What makes it hard to take is that typically, when someone says something like, “I already know all that Rogerian stuff,” it’s a surefire sign that they really don’t get person-centered therapy.

Although this is mostly just my opinion, it’s also the opinion of Natalie Rogers (daughter of Carl Rogers, the person who originally developed person-centered therapy). The following is an edited excerpt of two telephone interviews I did with her way back in 2003. This excerpt is included in our theories textbook: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/0470617934/ref=cm_cr_pr_product_top?ie=UTF8

Additional interview material is in an article published in the Journal of Counseling and Development in 2007: http://onlinelibrary.wiley.com/doi/10.1002/j.1556-6678.2007.tb00454.x/abstract

And even more interview material is resting on the hard-drive of my computer.

Other fun and interesting content about person-centered therapy is in our Student Guide: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/0470904372/ref=sr_1_fkmr1_1?s=books&ie=UTF8&qid=1438700878&sr=1-1-fkmr1&keywords=sommers-flanagan+student+guide

Here’s what Natalie had to say about the status of Person-Centered Therapy in the U.S.

Why Is the Person-Centered Approach Undervalued in the United States?

In the following excerpt from two telephone interviews, Natalie Rogers discusses why person-centered approaches tend to be undervalued or overlooked in the United States.

John Sommers-Flanagan (JSF): Other than the managed-care focus and an emphasis on quick fixes, can you think of any reasons why more American therapists aren’t practicing PCT?

Natalie Rogers (NR): That’s a good question. Most psychology students I know only get a chapter or two in the academic world, and they don’t really understand in any depth what the person-centered approach is about. And, most importantly, I think they haven’t experienced it. They’ve read [about] it and they’ve talked about it and they’ve analyzed it, but my own belief is that it really takes in-depth experiencing of the client-centered approach to know the healing power of empathy and congruence and unconditional positive regard.

JSF: So it’s almost like students get more of an intellectual understanding, but you’re just not seeing them get the experiential part.

NR: Even the intellectual understanding is very superficial, because they read maybe a chapter and watch the old Gloria film (Rogers, 1965). The fact that there have been 16 books written on client-centered therapy and a lot of other books now that Carl’s passed away and the research that he did is so profound . . . the in-depth research on what actually helps clients go deeper into their feelings and thoughts.

JSF: Right.

NR: You know, [how therapists can help clients go deeper into their feelings and thoughts] is hardly ever mentioned in academia as far as I know.

JSF: And what I remember from our last conversation was that you said you thought it didn’t happen in the U.S. at all and maybe a little bit in Europe?

NR: I think it does happen a lot more in Europe, and most particularly in the United Kingdom, Scotland and England. They have really excellent training programs in the client-centered approach, and the books that are coming out are coming out from there. You know in Germany they have a several-year, very extensive training program that’s also linked in, I believe, to becoming accredited or licensed as a therapist. Things are going that particular route in Europe, but none of that is here in the States.

JSF: That seems to reflect our own emphasis on the surface or the quick fix as well in that people just really haven’t gone deeper and experienced the power of PCT.

NR: Right. And then again I think the other point is that the ego needs of the therapists [appear] to be strong here. Therapists in this country seem to need to have the attitude that “I have the answers” or at least that “I know more,” and it’s . . . the old medical model that we still hold onto in this country a lot. The doctor knows what he needs to diagnose and treat, knows what’s wrong and that there are ten steps to fix it.

JSF: Right, which seems to be the opposite of the person-centered therapy of “trust the individual, trust the person.”

NR: Not just seems to be, it is the opposite. So, to actually believe, to have faith in the individual, to have faith that each person has the answers within himself or herself if given the proper conditions, and that’s a big if. That philosophy takes a great deal of humility on the part of the therapist.

JSF: For us to realize that we don’t have all the answers for another person.

NR: Right. I kind of like the gardener metaphor. That I’m the gardener and I help till the soil and I help water the plants and fertilize the plants, and care for them. And I need to understand what the plant needs, what conditions that plant needs for it to actually grow and become its full potential. That’s very different. That’s what I see as one metaphor for being a therapist. I don’t know all the answers, but I’m a person who creates the conditions for the person to grow.

JSF: Kind of the fertile field metaphor. So . . . what would you tell beginning therapists that would help them see the tremendous value of following person-centered principles?

NR: Well, I always ask my students to examine their own beliefs about psychotherapy and about what it is that creates psychological feelings and growth. I think it’s a philosophical, spiritual belief system that we’re looking at. People are using the words “methods” and “techniques,” which always puts me off, because although there certainly are methods that we use, it’s much bigger than that. It’s a belief system about the connection between mind, body, and emotional spirit. And so I ask them what do they believe creates personal growth, and what have they experienced themselves that creates growth, and we get them to think and talk about their religious experiences, their psychotherapy experiences, their experiences in nature, and their experiences in relationships. I think they’re all profound. And then when we focus in on relationships, which is what psychotherapy is about, then I want them to experience . . . from me or my colleagues in hour-long demonstrations what it means to be client-centered. So then they experience it as witnesses and they can experience it as a client.

JSF: So more students need to directly experience, or at least witness, client-centered therapy.

NR: Let me give an example. I was talking to a colleague once who had some of my training and who said that he was now using brief therapy, brief psychotherapy, and I admitted I didn’t really know what that was. We decided that he’d have to give me some ideas on what that’s like. So I listened to him describe the theory and practice for quite a while and questioned him about it. And as he was describing it, I was wondering, how would I feel if I were in the client’s chair and this was what was being done to me. And so then I felt pretty uncomfortable, and thought, “I guess I wouldn’t like it.” So I asked him, “Have you ever been a client in this kind of brief therapy yourself?” And he said “No,” and I thought that was inexcusable. To practice something on somebody else that you haven’t experienced in-depth yourself. I think it is inexcusable. So that illustrates in a kind of negative way the point that I wanted to make. You really need to have in-depth experience of that which you are going to have other people do.