Tag Archives: Psychotherapy

Introductions and Full Disclosure (at least in part)

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

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

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

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

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

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

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

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

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

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

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

John Dancing at a Wedding Reception

 

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Teaching Counseling and Psychotherapy Theories: Reflections on Week 1

Teaching Counseling and Psychotherapy Theories – Week 1

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

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

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

Activity 1: Creating and Testing Personal Hypotheses

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

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

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

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

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

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

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

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

Hypothesis 1:

 

Hypothesis 2:

 

Hypothesis 3:

 

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

Activity #2: A Psychological Assessment Critique

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

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

1.

 

2.

 

3.

 

4.

 

5.

 

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

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

John’s Answers

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

 

Two Sample Mental Status Examination Reports

JSF Dance Party

This is a photo of me checking my mental status.

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

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

Sample Mental Status Examination Reports

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

1.  Appearance

2.  Behavior/psychomotor activity

3.  Attitude toward examiner (interviewer)

4.  Affect and mood

5.  Speech and thought

6.  Perceptual disturbances

7.  Orientation and consciousness

8.  Memory and intelligence

9.  Reliability, judgment, and insight

The following reports are provided as samples.

Mental Status Report 1

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

Mental Status Report 2

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

 

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

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

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

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

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

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

 Image

John offers his brother-in-law some advice.

A Wiley Website with Info about our Brand New Counseling and Psychotherapy Videos

This spring and summer Rita and I have been working with John Wiley & Sons to produce DVDs to go with our textbooks Clinical Interviewing and Counseling and Psychotherapy Theories in Context and Practice. The Clinical Interviewing DVD is out and the Theories DVD will be available soon. There’s a new website with information about this at: http://lp.wileypub.com/SommersFlanagan/

Image

John reading the new textbooks to his twin grandchildren (who look quite excited about learning how to do psychotherapy).

 

Is Solution-Focused Therapy as Powerfully Effective as Solution-Focused Therapists Would Have Us Believe?

[This Blog is adapted from a previous blog posted on psychotherapy.net]

Solution-focused therapy is very popular. But is it effective?

Beginning in the 1980s, solution-focused therapy hit the mainstream and many mental health providers (and third-party payers) continue to sing the praises of its brevity and effectiveness. For example, in a 2009 book chapter Sara Smock claimed, “. . . there are numerous studies, several reviews of the research, and a few meta-analyses completed that showcase [solution-focused therapy’s] effectiveness.”

Really?

Solution-focused counseling and psychotherapy has deep roots in post-modern constructive theory. As Michael Hoyt once famously articulated, this perspective is based on “the construction that we are constructive.” In other words, solution-focused therapists believe clients and therapists build their own realities.

Ever since 2003, my personal construction of reality has been laced with skepticism. That was the year President George W. Bush included 63 references to “weapons of mass destruction” in his State of the Union address (I’m estimating here, using my own particular spin, but that’s the nature of a constructive perspective). As it turned out, there were no weapons of mass destruction, but President Bush’s “If I say it enough, it will become reality” message had a powerful effect on public perception.

From the constructive or solution-focused perspective, perception IS reality. Remember that. It applies to the solution-focused therapist’s view of solution-focused therapy effectiveness.

I recall hearing many presenters tell me that solution-focused therapy is powerful and effective. Or maybe it was powerfully effective. And I recall reading books and articles that similarly referred to the power and effectiveness of solution-focused therapy. Now we could just take their word for it, but I still can’t help but wonder: “What does the scientific research say about the efficacy of solution-focused therapy anyway?”

Here’s a quick historical tour of scientific reality.

  • In 1996, Scott Miller and colleagues noted: “In spite of having been around for ten years, no well-controlled, scientifically sound outcome studies on solution-focused therapy have ever been conducted or published in any peer-reviewed professional journal.”
  • In 2000, Gingerich & Eisengart identified 15 studies and after analyzing the research, they stated: “. . . we cannot conclude that [solution-focused brief therapy] has been shown to be efficacious.”
  • In 2008, Johnny Kim reported on 22 solution-focused outcomes studies. He noted that the only studies to show statistical significance were 12 studies focusing on internalizing disorders. Kim reported an effect size of d = .26 for these 12 studies [this is a rather small effect size].
  • In 2009, Jacqueline Corcoran and Vijayan Pillai concluded: “. . . practitioners should understand there is not a strong evidence basis for solution-focused therapy at this point in time.”

Now don’t get me wrong. As a mental health professional and professor, I believe solution-focused techniques and approaches can be very helpful . . . sometimes. However, my scientific training stops me from claiming that solution-focused approaches are highly effective. Although solution-focused techniques can be useful, psychotherapy often requires long term work that focuses not only on strengths, but problems as well.

So what’s the bottom line?

While in a heated argument with an umpire, Yogi Berra once said: “I wouldn’t have seen it if I hadn’t believed it!” This is, of course, an apt description of the powerful confirmation bias that affects everyone. We can’t help but look for evidence to support our pre-existing beliefs . . . which is one of the reasons why even modernist scientific research can’t always be trusted.  But this is why we bother doing the research. We need to step back from our constructed and enthusiastic realities and try to see things as objectively as possible, recognizing that absolute objectivity is impossible.

Despite strong beliefs to the contrary, there were no weapons of mass destruction. And currently, the evidence indicates that solution-focused therapy is NOT powerfully effective.

 

John Dreams About Counseling and Psychotherapy Theories

One morning, long ago, John woke up in the midst of a dream about having written a theories book. Over breakfast, John shared his dream with Rita. Rita said, “John go sit down, relax, and I’ll sit behind you as you free associate to the dream” (see Chapter 2, Psychoanalytic Approaches).

As John was free-associating, Rita tried to gently share her perspective using a two-person, relational psychotherapy model. She noted it had been her lived experience that, in fact, they had already written a theories text together and that he must have been dreaming of a 2nd edition. John jumped out of his seat and shouted, “You’re right! I AM dreaming about a 2nd edition.”

This profound insight led to further therapeutic exploration. Rita had John look at the purpose of his dream (see Chapter 3, Individual Psychology); then he acted out the dream, playing the role of each object and character (see Chapter 6; Gestalt therapy). When he acted out the role of Rita, he became exceedingly enthusiastic about the 2nd edition. She, of course, accused him of projection while he suggested that perhaps he had absorbed her thoughts in a psychic process related to Jung’s idea of the collective unconscious. Rita noted that was a possibility, but then suggested we leave Jung and the collective unconscious online where it belongs (see the Jungian chapter in the big contemporary collective unconscious of the internet online at ** ).

For the next week, Rita listened to and resonated with John as he talked about the 2nd edition. She provided an environment characterized by congruence, unconditional positive regard, and empathic understanding (see Chapter 5, Person-Centered approaches). John flourished in that environment, but sneakily decided to play a little behavioral trick on Rita. Every time she mentioned the word theories he would say “Yesss!,” pat her affectionately on the shoulder and offer her a piece of dark chocolate (see Chapter 7, Behavior therapy). Later he took a big risk and allowed a little cognition into the scenario, asking her: “Hey, what are you thinking?” (see Chapter 8, Cognitive-behavioral therapy).

Rita WAS still thinking it was too much work and not enough play. John responded by offering to update his feminist views and involvement if she would only reconsider (see Chapter 10, Feminist therapy); he also emphasized to Rita that writing a second edition would help them discover more meaning in life and perhaps they would experience the splendor of awe (see Chapter 4, Existential therapy). Rita still seemed ambivalent and so John asked himself the four questions of choice theory (see Chapter 9, Choice theory and reality therapy):

  1. What do you want?
  2. What are you doing?
  3. Is it working?
  4. Should you make a new plan?

It was time for a new plan, which led John to develop a new narrative (see Chapter 11, Narrative therapy).  He had a sparkling moment where he brought in and articulated many different minority voices whose discourse had been neglected (see Chapter 13; Multicultural therapy). He also got his daughters to support him and conducted a short family intervention (see Chapter 12, Family systems therapy).

Something in the mix seemed to work: Rita came to him and said . . . “I’ve got the solution, we need to do something different while we’re doing something the same and approach this whole thing with a new attitude of mindful acceptance” (see Chapter 11, Solution-focused therapy and Chapter 14, Integrational approaches). To this John responded with his own version of radical acceptance saying: “That’s a perfect idea and you know, I think it will get even better over a nice dinner.” It was at that nice dinner that they began to articulate their main goals for the second edition of Counseling and Psychotherapy Theories in Context and Practice.