Tag Archives: Psychotherapy

Tough Kids, Cool Counseling: Dealing with “Resistance” – Part 1

Working with challenging, tough, or naturally resistant youth is one of the most difficult situations a counselor or psychotherapist can face. In this excerpt from chapter 3 of “Tough Kids, Cool Counseling” (published by ACA, 2007), we begin discussing strategies for dealing with this difficult situation. Here’s a link to the Amazon page for this book: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_2?ie=UTF8&qid=1370790501&sr=1-2

Chapter 3

Resistance Busters: Quick Solutions and Longer-Term Strategies

As noted in preceding chapters, adolescents are well-known for their general distrust of adults and their striving for autonomy (Erikson, 1963; Saginak, 2003). Despite this distrust and independence-striving, in most cases, by using the strategies and techniques discussed in Chapter 2, counselors can manage resistance and initiate therapy with clients and their parents. However, upon entering a counseling situation, some young people will display extreme, provocative, or puzzling resistance behaviors that require more specialized approaches (Amatea, 1988; Richardson, 2001).

Imagine the following scenario:

You’re an intern scheduled to meet with a 15-year-old girl referred to a community clinic from a local group home. You’ve been in graduate school for about 18 months and so you’re not completely naïve, but because you’re only 23 years old yourself (and you went through a fair bit of emotional turmoil during your teen years), you’re especially excited about the opportunity to help a teenager who is obviously in a challenging life situation.

When you meet your client, Maya, in the waiting room, your enthusiasm begins to wane. Her jet-black and pink fringed hair hangs over her eyes and she reeks of cigarette smoke. When you greet her, she sneers, causing her lip-ring to flip upward. Her eyes (or at least what you can see of them) roll back as if she is disgusted at the sight of you.

Her first spoken words to you are: “This is a fucking waste of my time.”

You’re not sure what to say and so the Carl Rogers voice inside of you says gently, “It sounds like you’re not very happy to be here.”

Maya’s response is to slip into a stony silence, a silence only occasionally broken with deep dramatic sighs. Eventually, when she finally speaks again, she says, “Oh my fucking God. And you’re supposed to help me?  That’s a joke.”

Some teenagers have a special talent for destroying their counselor’s confidence. Not surprisingly, our graduate students, when facing a client like Maya for the first time, are often stunned. They complain of having a blank-mind and not knowing what to say. Other common reactions to the Maya-prototype include overwhelming feelings of inadequacy (usually accompanied by anxiety) or strong impulses to retaliate with anger.

This chapter focuses on strategies and techniques for dealing with some of the most provocative behaviors you’re likely to see in counseling situations. Our belief is that counselors should prepare, plan, and look forward to aggressive resistance from teenage clients or students. Again, we emphasize that aggressive resistance is best viewed as a coping style brought into the counseling situation and directed towards anyone in authority—in Sullivan’s terms, a parataxic distortion (Sullivan, 1953). Therefore, when working with challenging youth, keep one key fact clearly in mind: Your client’s insults, disgust, and aggressive behavior, although aimed at you, have virtually nothing to do with you. There’s no point in taking your client’s comments personally, and in fact, if you can side-step the onslaught, it will provide you with all sorts of important diagnostic and clinical information about your client’s pain and defenses.

Getting Your Buttons Pushed

Despite our great advice about not taking your client’s degrading comments personally, in the real world, we all get our buttons pushed sometimes. A graphic example of counselor over-reaction to provocative client behavior was captured in the feature film, Good Will Hunting (Van Sant, 1997).

As a fan of counseling, you may recall the scene. The main character, Will, played by Matt Damon, is an extremely intelligent but emotionally disturbed young man with mathematical genius. His would-be mentor, in an effort to help Will fulfill his potential, sends him to several different counselors, none of whom are able to help Will. Finally, Will ends up in the office of Sean McGuire, played by Robin Williams.

During his initial session with McGuire, Will is his provocative and nasty self. He eventually, either accidentally, or via great intuition, begins insulting McGuire’s deceased wife and because he is still unresolved about his wife’s premature death, McGuire gets his emotional buttons pushed. The result: the counselor grabs Will around the neck and slams him up against the wall. Of course, McGuire also decides to take on Will as a client and successfully helps Will move forward in his life.

We would like to emphasize two key points related to this excellent example of resistance and countertransference from Good Will Hunting. First, be aware of your emotional buttons, seeking the support and counseling you need to be an effective and ethical counselor. Second, no matter how provocative your young clients may act, avoid using Robin Williams’s “Choking the client” technique.  It may play well in Hollywood, but physical contact with resistant, aggressive, and/or angry clients is highly ill-advised.

If you find you’re having your emotional buttons pushed occasionally by teenage clients or students, consider yourself normal. On the other hand, if the button pushing begins to cause you to contemplate acting on destructive impulses, it’s time to get therapy for yourself, and/or support from a collegial supervision group. Many psychoanalytically-oriented writers have warned about the powerful regressive countransference impulses that young clients can ignite in their counselors (Dass-Brailsford, 2003; Horne, 2001).

Pause for Reflection: How do you usually respond when you get your buttons pushed by someone? Do you instantly feel angry? Or, are you more likely to scrutinize yourself and decide that you really are just an inadequate and worthless piece of furniture? Of course, there’s no “right” response to these questions. The best guideline is to continually work at looking at yourself and your reactions to clients so that you are consistently cultivating your self-awareness.

[End of Pause for Reflection]

To work ethically and professionally with provocative clients requires general skill, personal insight, and a particular knowledge base that includes a range of potentially constructive automatic or formula responses.

Sara Pranks John During the Theories Video Production

When the psychoanalytically-oriented demo session begins and Sara starts talking about a repeating dream she had that involved some ferns, a cave, and a pickle, he quickly realizes he’s in trouble. Somehow an earlier version of this video was cut short on this website and so I’m trying to post this again.

Recommendations for Developing and Using a Positive Working Alliance

Although Freud started the conversation, he might not recognize contemporary models of the working alliance. This is because Freud advocated analyst emotional distance and a detached psychoanalytic stance, whereas today’s working alliance involves therapists initiating a process of collaborative engagement with clients.

Therapists who want to develop a positive working alliance (and that should include all therapists) will integrate strategies for doing so during initial interviews and beyond. Based on Bordin’s (1979) model, alliance-building strategies would focus on (a) collaborative goal setting; (b) engaging clients on mutual therapy-related tasks; and (c) development of a positive emotional bond. Additionally, feedback monitoring within clinical interviews is recommended.

Initial interviews and early sessions appear especially important to developing a working alliance. Many clients who enter your office will be naïve about what will be happening in their work with you. This makes including role inductions or explanations of how you work with clients essential. Here’s an example from a cognitive-behavioral perspective:

For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)

Asking direct questions about what clients want from counseling and then listening to them and integrating that information into your treatment plan is also important: In cognitive therapy this is often referred to as making a problem list (J. Beck, 2011).

Therapist:    What brings you to counseling and how can I be of help?

Client:         I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.

Therapist:    Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we write, “Find ways to help you start feeling more up?”

Client:         Sounds good to me.

Engaging in a collaborative goal-setting process—and not proceeding with therapy tasks until it’s clear that mutual goals (even temporary mutual goals) have been established

Therapist:    So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?

Client:         Absolutely yes. If we can climb those three mountains it will be great.

Soliciting feedback from clients during the initial session and ongoing in an effort to monitor the quality and direction of the working alliance. Although there are a number of instruments you can use for this, you can also just ask directly:

We’ve been talking for 20 minutes now and so I just want to check in with you on how you’re feeling about talking with my today. How are you doing with this process?

Making sure you’re able to respond to client anger or hostility without becoming defensive or launching a counterattack is essential to establishing and maintaining a positive working relationship. In our work with challenging young adults, we apply Linehan’s (1993) “radical acceptance” concept. For example, an initial session with an 18-year-old male started like this:

Therapist:    I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:         You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).

Therapist:    Thanks for telling me about that. I definitely want to avoid getting punched in the nose. And so if I accidentally say anything that offends you I hope you’ll tell me, and I’ll try my best to stop.

In this case the therapist accepted the client’s aggressive message and tried to transform it into a working concept in the session.

Having specific therapy tasks (no matter your theoretical orientation) that fit well with the mutually identified therapy goals. For example, if illuminating unconscious processes is a mutually identified goal, then using free association can be a task that makes sense to the client. On the other hand, if you’ve agreed to work toward greater self-acceptance and greater acceptance of frustrating people in the client’s life, then engaging in intermittent mindfulness tasks will feel like a reasonable approach.

 

Why Therapists Should Never Say, “I know how you feel”

The following excerpt is adapted from the fifth edition of the text, Clinical Interviewing (John Wiley & Sons, 6th edition forthcoming in October).

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Many writers have tried operationalizing Carl Rogers’s core conditions. However, efforts to transform person-centered therapy core conditions into specific behavioral skills always seem to fall short. As Natalie Rogers (J. Sommers-Flanagan, 2007) emphasized, trying to translate the core conditions into concrete behaviors is usually a sign that the writer or therapist simply doesn’t understand person-centered principles.

This lack of understanding occurs principally because core Rogerian attitudes are attitudes, not behaviors. This is a basic conceptual principle that has proven difficult to understand—perhaps especially for behaviorists. The point Rogers was making then (in the 1950s), and that still holds today, is that therapists should enter the consulting room with (a) deep belief in the potential of the client; (b) sincere desire to be open, honest, and authentic; (c) palpable respect for the individual self of the client; and (d) a gentle focus on the client’s inner thoughts, feelings, and perceptions. Further complicating this process is the fact that the therapist must rely primarily on indirectly communicating these attitudes because efforts to directly communicate trust, congruence, unconditional positive regard, and empathic understanding is nearly always contradictory to each of the attitudes.

A counselor educator friend of ours, Kurt Kraus, articulated why trying to directly communicate understanding is problematic. He wrote:

When a supervisee errantly says, “I know how you feel” in response to a client’s disclosure, I twitch and contort. I believe that one of the great gifts of multicultural awareness is for me accepting the limitations to the felt-experience of empathy. I can only imagine how another feels, and sometimes the reach of my experience is so short as to only approximate what another feels. This is a good thing to learn. I’ll upright myself in my chair and say, “I used to think that I knew how others felt too. May I teach you a lesson that has served me well?” (J. Sommers-Flanagan & Sommers-Flanagan, 2012) (p. 146)

Kraus’s lesson is an excellent one for all of us. The phrases, “I know how you feel” and “I understand” should be stricken from the vocabulary of counselors and psychotherapists.

Your Life is Now: Trapper Creek Reflections

The Road

Note: This is a re-post. I had a chance to drive to Trapper this past week with one of our doc students and I was reminded of the powerful life experiences that happen at Trapper Creek Job Corps.

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Sometimes on Thursday or Fridays I drive from Missoula to Trapper Creek Job Corps. Then I drive back the same day. It’s a 140 mile round trip. Sometimes I have interns with me. The company makes the miles go by more quickly. Sometimes the interns are very nervous sitting next to me for the whole drive and consequently compete to see who gets the back seat. This makes me wonder if maybe I shouldn’t quiz them about theories of counseling and psychotherapy as we drive there together. Although I wonder about this . . . I haven’t changed my behavior. Maybe this means I’m trying to scare them all into the back seat.

This week I was on my own. When this is the case I usually begin wondering why the heck I drive all these miles. Of course, I get paid to go to Trapper Creek. That’s one answer I give to myself. But I keep wondering anyway. It’s a long day, usually 11 or 12 hours. And when I’m about halfway there, 45 minutes into dodging deer with 45 more minutes to deal with Bitterroot drivers, I begin planning my retirement from Trapper Creek.

This is my 10th year (2013). I know the road and I know the deer and I know the Bitterroot drivers, who, in an apparent show of independence, nearly always drive either 10 mph under or 10 mph over the speed limit.

Today my retirement planning ended shortly after arriving at Trapper Creek. There were three straight appointments scheduled for me: three straight chances to do something more than talk about how to do psychological assessment and psychotherapy. And then a chance to observe and give feedback to the nursing staff and a chance to offer my unsolicited opinion to the physician on how to deal with an ingrown toenail and then a fourth student to see and a staff consultation and a meeting and a quick hello to our three University of Montana school counseling interns and wild typing of reports and poof . . . the day is over without a moment to ponder life or reflect on retirement.

The drive back to Missoula is nearly always better. There are stories to tell, opportunities to second guess myself, and unrealistic hopes and fantasies about having possibly helped someone. The miles melt away.

[The following stories are vague and distorted to preserve anonymity]

Today, with no interns for company my buddy John Cougar Mellencamp joined me on the drive back. We decided to sing together. We sang the same song so many times we lost count.

Your Life is Now

This is your time . . . to do what you will do

The first two young women were graduating from Trapper and moving on to advanced Job Corps training. They needed brief clinical interviews and mental status exams. These two hard working and delightful young women are at Trapper because they’ve experienced poverty and want to improve their lives.

Your life is now

One had a history of having been diagnosed with two severe mental disorders. Before coming to Trapper she’d been on two very powerful psychotropic medications. Funny thing: At Trapper she attained a very high level of functioning without medications . . . for nine straight months!

Your life is now

She had many “citations” for positive behavior. The staff love her. There was no shred of evidence that she had a mental disorder. So I just told her so. She grinned, looked at me, and said, “I guess that’s pretty good news.” Yep, pretty good news.

Your life is now

The second young woman was equally impressive.

In this undiscovered moment

But my last appointment, a young man with a history of trauma, really made my day.

We had visited two weeks previously and had made a plan to try some EMDR for his troubling trauma symptoms. He was eager and right on time. We talked briefly to warm up. He chose a memory. We went through various rating procedures included in the EMDR protocol.

Lift your head up above the crowd

We did several sets of eye movements. I did my usual wandering in and out of the “proper” EMDR protocol. After 10 minutes, we stopped and I asked him to reflect on his experience. He turned his head back and forth and said, “My neck doesn’t hurt anymore.”

We could shake this world

Then he smiled and said, “I feel like I can breathe again.” And then, “I wish I’d known about this ten years ago.”

If you would only show us how

Thank you Trapper Creek

Thank you fine young women and men

Thank you nurses and doctor and interns and staff

Thank you deer and Bitterroot drivers

Thank you for showing me how to shake this world and make a difference.

 Your life is now

Information on Suicide Interventions for Counselors

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

Safety Planning

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

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

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

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

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

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

Identifying Alternatives to Suicide

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

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

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

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

Separating the Psychic Pain From the Self

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

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

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

Tough Kids Image

Through the Anger Looking Glass

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

Through the Anger Looking Glass

By John Sommers-Flanagan

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

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

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

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

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

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

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

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

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