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:
Recognizing warning signs of an impending suicidal crisis
Employing internal coping strategies
Utilizing social contacts as a means of distraction from suicidal thoughts
Contacting family members or friends who may help to resolve the crisis
Contacting mental health professionals or agencies
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.
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:
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.
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.
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.
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.
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.
As a part of reviewing information for this chapter, we perused Internet therapy options available to potential consumers. Previous publications suggested a possible plethora of Internet counseling and psychotherapy providers with questionable professional credentials (Heinlen, Welfel, Richmond, & O’Donnell, 2003; Shaw & Shaw, 2006). Although we hoped that Internet service provision standards had improved, we weren’t overly impressed with our results. Generally, we found that most providers may have more expertise in business and marketing than they do in professional clinical work. Affixed on this foundation of business and marketing, we found two distinct approaches: the more ethical and the less ethical.
The Less Ethical Approach
Many providers offer online services but don’t acknowledge having specific credentials (e.g., a license) typically associated with clinical expertise. For example, practitioners with bachelor’s degrees (or less) made statements like the following:
“I am a counselor, life coach, and spiritual teacher with over 20 years of experience. I have studied the fields of counseling, psychology, personal growth, relationships, communications, business, computer programming and technology, languages, spirituality, metaphysics and energetic bodywork! In addition to my training, a [sic] 18-year relationship with my second husband has deepened my capacity to help others with relationship issues.”
This sort of enthusiastic introduction was typically followed by an equally enthusiastic statement about the breadth of services offered:
“My online counseling services specialties include, but are not limited to: anxiety/panic, self-esteem, highly sensitive people, couples counseling, relationship advice, life and career coaching, emotional intelligence, personal growth, affairs, guilt issues, work and career, trust issues, abuse/boundary issues, communication skills, conflict resolution, grief and loss, emotional numbness, spiritual development, stress management, blame, court-ordered counseling, codependency, problem resolution, jealousy, codependency and attachment, anger and depression, food and body, and developing peace of mind.”
Curiously, we found that the broad range of claims on websites such as these did not move us toward developing or experiencing peace of mind.
The More Ethical Approach
There were also websites that included professional, licensed providers. For example, one website listed and described eight licensed practitioners with backgrounds in professional counseling, social work, and psychology. These professionals offered webcam therapy, text therapy, e-mail therapy, and telephone therapy.
E-mail therapy: $25 per online counselor reply
Unlimited e-mail therapy: $200 per month
Chat therapy: $45 per 50-minute session
Telephone therapy: $80 per 50-minute session
Webcam therapy: $80 per 50-minute session
The more ethical professional Internet services also tended to include information related to theoretical orientation. For example, a “postmodern” approach was described as involving: “Staying positive . . . focused on the here and now . . . offering solutions that meet your needs . . . a collaborative and respectful environment . . . quick results . . .”
How to Choose an Internet Services Provider
The National Directory of Online Counselors now exists to help consumers choose an online provider. They state:
“We have personally verified the credentials and the websites of each therapist listed in the National Directory of Online Counselors. Feel assured that the therapists listed are state board licensed, have a Master’s Degree or Doctoral Degree in a mental health discipline, and have online counseling experience.”
The listed therapists and websites are set up and ready to handle secure communication, and offer various services such as eMail Sessions, Chat Sessions, and Telephone Sessions. All work conducted by the professional licensed therapists meet[s] strict confidentiality standards overseen by their professional state board.
Both of these distinct approaches to online therapy emphasize that help is only a mouse click away.
Empathic understanding is a central concept in counseling and psychotherapy. Rogers (1980) defined empathy as:
. . . the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. [It is] this ability to see completely through the client’s eyes, to adopt his frame of reference, (p. 85) . . . It means entering the private perceptual world of the other . . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . . . It means sensing meanings of which he or she is scarcely aware. (p. 142)
Rogers’s definition of empathy is complex. It includes several components.
Therapist ability or skill
Therapist attitude or willingness
A focus on client thoughts, feelings, and struggles
Adopting the client’s frame of reference or perspective-taking
Entering the client’s private perceptual world
Moment-to-moment sensitivity to felt meanings
Sensing meanings of which the client is barely aware
A Deeper Look at Empathy
As with congruence and unconditional positive regard, the complexity of Rogers’s definition has made research on empathy challenging. Many different definitions of empathy have been articulated (Batson, 2009; Clark, 2010; Duan & Hill, 1996). According to Elliott, Bohart, Watson, & Greenberg (2011), recent advances in neuroscience have helped consolidate empathy definitions into three core subprocesses:
Emotional simulation: This is a process that allows one person to experientially mirror another’s emotions. Emotional simulation likely involves mirror neurons and various brain structures within the limbic system (e.g., insula).
Perspective-taking: This is a more intellectual or conceptual process that appears to involve the pre-frontal and temporal cortices.
Emotion regulation: This involves a process of re-appraising or soothing of one’s own emotional reactions. It appears to be a springboard for a helping response. Emotional regulation may involve the orbitofrontal cortex and prefrontal and right inferior parietal cortices.
Empathy is an interpersonal process that requires experiencing, inference, and action. In chapter 1 we noted that playing a note on one violin will cause a string on another violin to vibrate as well, albeit at a lower level. In therapy, this has been referred to as resonance. Most people have had the experience of feeling tears well up at a movie or while someone talks about pain or trauma. This is the experiential component of empathy that Elliot et al., (2011) referred to as emotional simulation).
Beyond this physical/experiential resonance, one person cannot objectively know another person’s emotions and thoughts. Consequently, at some level, empathy always involves subjective inference. This process has been referred to as perspective-taking in the scientific literature and is considered a cognitive or intellectual requirement of empathy (Stocks, Lishner, Waits, & Downum, 2011).
Empathy—at least within the context of a clinical interview—also requires action. Therapists must cope with and process the emotions that are triggered and then provide an empathic response. Most commonly this involves reflection of feeling or feeling validation, but nearly every potential interviewing response or behavior can include verbal and nonverbal components that include empathy. The action component of empathy is likely what Elliot et al., are referring to with the term emotional regulation.
Simple guides to experiencing and expressing empathy can help you develop your empathic abilities. At the same time, we don’t believe any single strategy will help you develop the complete empathy package. For example, Carkhuff (1987) referred to the intellectual or perspective-taking part of empathy as “asking the empathy question” (p. 100). He wrote:
By answering the empathy question we try to understand the feelings expressed by our helpee. We summarize the clues to the helpee’s feelings and then answer the question, How would I feel if I were Tom and saying these things? (p. 101).
Carkhuff’s empathy question is a useful tool for tuning into client feelings, but it also oversimplifies the empathic process in at least two ways. First, it assumes therapists have a perfectly calibrated internal affective barometer. Unfortunately this is not the case as clients and therapists can have such different personal experiences that the empathy question produces completely inaccurate results; just because you would feel a particular way if you were in the client’s shoes doesn’t mean the client feels the same way. Sometimes empathic responses are a projection of the therapist’s feelings onto the client. If you rely solely on Carkhuff’s empathy question, you risk projecting your own feelings onto clients.
Consider what might happen if a therapist tends towards pessimism, while her client usually puts on a happy face. The following exchange might occur:
Client: “I don’t know why my dad wants us to come to therapy now and talk to each other. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would accept it too.”
Therapist: “It must make you angry to have a father who can’t communicate effectively with you.”
Client: “Not at all. I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”
In this case, asking the empathy question: “How would I feel if I could never communicate well with my father?” may produce angry feelings in the therapist. This process consequently results in the therapist projecting her own feelings onto the client—which turns out to be a poor fit for the client. Accurate empathic responding stays close to client word content and nonverbal messages. If this client had previously expressed anger or was looking upset or angry (e.g., angry facial expression, raised voice), the therapist might resonate with and choose to reflect anger. However, instead the therapist’s comment is inaccurate and is rejected by the client. The therapist could have stayed more closely with what her client expressed by focusing on key words. For example:
Coming into therapy now doesn’t make much sense to you. Maybe you used to have feelings about your lack of communication with your dad, but it sounds like at this point you feel pretty numb about the whole situation and just want to move on.
This second response is more accurate. It touches on how the client felt before, what she presently thinks, as well as the numbed affective response. The client may well have unresolved sadness, anger, or disappointment, but for the therapist to connect with these buried feelings requires a more interpretive intervention. Recall from Chapter 3 that interpretations and interpretive feeling reflections must be supported by adequate evidence.
To help with the intellectual process of perspective-taking, instead of focusing exclusively on what you’d feel if you were in your client’s shoes, you can expand your repertoire in at least three ways:
Reflect on how other clients have felt or might feel
Reflect on how your friends or family might feel and think in response to this particular experience
Read and study about experiences similar to your clients’.
Based on Rogers’s writings, Clark (2010) referred to intellectual approaches to expanding your empathic understanding as objective empathy. Objective empathy involves using “theoretically informed observational data and reputable sources in the service of understanding a client” (Clark, 2010, p. 349). Objective empathy is based on the application of external knowledge to the empathic process—this can expand your empathic responding beyond your own personal experiences.
Rogers (1961) also emphasized that feeling reflections should be stated tentatively so clients can freely accept or dismiss them. Elliot et al., (2011) articulated the tentative quality of empathy very well: “Empathy should always be offered with humility and held lightly, ready to be corrected” (p. 147)
From a psychoanalytic perspective, it’s possible to show empathy not only for what clients are saying, but also for their defensive style (e.g., if they’re using defense mechanisms such as rationalization or denial, show empathy for those):
Client: “I don’t know why my dad wants us to come to therapy now. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would.”
Therapist: “Coming into therapy now doesn’t make much sense to you. Maybe you had feelings about your lack of communication with your dad before, but it sounds like you feel pretty numb about the whole situation now.”
Client: “Yeah, I guess so. I think I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”
Therapist: “Maybe one of the ways you protect yourself from feeling anything is to distance yourself from your parents. Otherwise, it could still bother you, I suppose.”
Client: “Yeah. I guess if I let myself get close to my parents again, my dad’s pathetic inability to communicate would bug me again.”
This client still has feelings about her father’s poor communication. One of the functions of accurate empathy is to facilitate the exploration of feelings or emotions (Greenberg, Watson, Elliot, & Bohart, 2001). By staying with the client’s feelings instead of projecting her own feelings onto the client, the therapist is more likely to facilitate emotional exploration.
A second way in which Carkhuff’s (1987) empathy question is simplistic is that it treats empathy as if it had to do only with accurately reflecting client feelings. Although accurate feeling reflection is an important part of empathy, as Rogers (1961) and others have discussed, empathy also involves thinking and experiencing with clients (Akhtar, 2007). Additionally, Rogers’s use of empathy with clients frequently focused less on emotions and more on meaning. Recall that in his original definition, Rogers wrote that empathy involved: “. . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . .” (p. 142). And so empathic understanding is not simple, it involves feeling with, thinking with, sensing felt meanings, and reflecting all this and more back to the client with a humility that acknowledges deep respect for the validity of the client’s own experiences.
More to come on this tomorrow in “Exploring Empathy” Part II.
Akhtar, S. (Ed.). (2007). Listening to others: Developmental and clinical aspects of empathy and attunement Lanham, MD, US: Jason Aronson.
Carkhuff, R. R. (1987). The art of helping (6th ed.). Amherst, MA: Human Resource Development Press.
Clark, A. J. (2010). Empathy: An integral model in the counseling process. Journal of Counseling & Development, 88, 348-356.
Greenberg, L. S., Watson, J. C., Elliot, R., & Bohart, A. C. (2001). Empathy. Psychotherapy: Theory, Research, Practice, Training, 38(4), 380-384.
Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.
Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.
Stocks, E. L., Lishner, D. A., Waits, B. L., & Downum, E. M. (2011). I’m embarrassed for you: The effect of valuing and perspective taking on empathic embarrassment and empathic concern. Journal of Applied Social Psychology, 41(1), 1-26. doi: http://dx.doi.org/10.1111/j.1559-1816.2010.00699.x
Adolescent clients are known for their tendency to push their psychotherapist’s emotional buttons. For example:
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).
If psychotherapists are not aware of how they are likely to react to emotionally provocative situations (such as the preceding) and prepared to respond with empathy, validation, and concession, they may not be well-suited to working with adolescent clients (Sommers-Flanagan & Richardson, 2011).
Nearly all adolescents have quick reactions to therapists and unfortunately these reactions are often negative, though some may be unrealistically positive (Bernstein, 1996). Adolescents may bristle at the thought of an intimate encounter with someone whom they see as an authority figure. Having been judged and reprimanded by adults previously, adolescents may anticipate the same relationship dynamics in psychotherapy. Therapists must be ready for this negative reaction (i.e., transference) and actively develop strategies to engage clients, lower resistance, and manage their own countertransference reactions (Sommers-Flanagan & Sommers-Flanagan, 2007).
And later in the article . . .
Based on clinical experience, we recommend opening statements or questions that are like invitations to work together. Adolescent clients may or may not reject the invitation, but because adolescent clients typically did not select their psychotherapist, offering an invitation is a reasonable opening. We recommend an invitation that emphasizes disclosure, collaboration, and interest and that initiates a process of exploring client goals. For example,
I’d like to start by telling you how I like to work with teenagers. I’m interested in helping you be successful. That’s my goal, to help you be successful in here or out in the world. My goal is to help you accomplish your goals. But there’s a limit on that. My goals are your goals just as long as your goals are legal and healthy.
The messages imbedded in that sample opening include: (a) this is what I am about; (b) I want to work with you; (c) I am interested in you and your success; (d) there are limits regarding what I will help you with. It is very possible for adolescent clients to oppose this opening in one way or another, but no matter how they respond, a message that includes disclosure, collaboration, interest, and limits is a good beginning.
And finally, photo that includes me and my professional coauthor.
Mondays are my theories evening this semester. Last night was feminist theory and therapy. We rocked our way through Women & Madness; Kinder, Kuche, and Kurche; and the Broverman et al. study to provide us with a foundation of justified anger which helped raise our collective consciousness and stimulate our instinct to tend and befriend and eventually develop an ethic of caring.
Below is the link to powerpoints from my second presentation at the WACES conference in Portland.
In theories class this past Monday Adler kicked Freud’s ass. This was, of course, metaphorical because Adler was radically anti-violent. Nevertheless, my Freud action figure ended up on the floor by the door where he had to lay there and listen to Adler’s repugnant (to Freud) ideas about how clients are affected by real (not fantasized) social dynamics or forces.
Below you can read a version of the Emotional Change Technique adapted from Tough Kids, Cool Counseling:
The Three-Step, Push-Button Emotional Change Technique
An early and prominent Adlerian therapist, Harold Mosak, originally developed and tested the push-button technique as a method for demonstrating to clients that thinking different thoughts can effectively change mood states (Mosak, 1985). The purpose of Mosak’s technique was to help clients experience an increased sense of control over their emotions, thereby facilitating a sense of encouragement or empowerment (Mosak, 2000, personal communication).
Mosak’s push-button technique can be easily adapted to work with young clients. When we implement this technique with younger clients, we are playful and call it an emotional change trick. When using this technique with teenagers, we describe it as a strategy for gaining more personal control over less desirable emotions. In essence, the three-step, push-button, emotional change technique is an emotional education technique; the primary goal is to teach clients that, rather than being at the mercy of their feelings, they may learn some strategies and techniques that provide them with increased personal control over their feelings.
The following example illustrates Adlerian emotional education principles and Mosak’s push-button technique expanded to three distinct steps.
Case example. Sam, a 13-year-old European American boy, was referred because of his tendency to become suddenly stubborn, rigid, and disagreeable when interacting with authority figures. Sam arrived for his appointment accompanied by his mother. It quickly became obvious that Sam and his mother were in conflict. Sam was sullen, antagonistic, and difficult to talk with for several minutes at the outset of the session. Consequently, the Three-Step, Push-Button Emotional Change Technique (TSPB) was initiated:
JSF: I see you’re in a bad mood today. I have this . . . well, it’s kind of a magic trick and I thought maybe you’d be interested. Want to hear about it?
JSF: It’s a trick that helps people get themselves out of a bad mood if they want to. First, I need to tell you what I know about bad moods. Bad moods are weird because even though they don’t really feel good, lots of times people don’t want to get out of their bad mood and into a better mood. Do you know what I mean? It’s like you kind of want to stay in a bad mood; you don’t want anybody forcing you to change out of a bad mood.
S: (Nods in agreement.)
JSF: And you know what, I’ve noticed when I’m in a bad mood, I really hate it when someone comes up to me and says: “Cheer up!” or “Smile!”
S: Yeah, I hate that too.
JSF: And so you can be sure I’m not going to say that to you. In fact, sometimes the best thing to do is just really be in that bad mood—be those bad feelings. Sometimes it feels great to get right into the middle of those feelings and be them.
S: Uh, I’m not sure what you’re talking about.
JSF: Well, to get in control of your own feelings, it’s important to admit they’re there, to get to know them better. So, the first step of this emotional change trick is to express your bad feelings. See, by getting them out and expressing them, you’re in control. If you don’t express your feelings, especially icky ones, you could get stuck in a bad mood even longer than you want.
As you can see, preparation for the TSPB technique involves emotional validation of how it feels to be in a bad mood, information about bad moods and how people can resist changing their moods or even get stuck in them, hopeful information about how people can learn to change their moods, and more emotional validation about how it feels when people prematurely try to cheer someone up.
Step 1: Feel the feeling. Before moving clients away from their negative feelings, it’s appropriate—out of respect for the presence and meaning of emotions—to help them feel their feelings. This can be challenging because most young people have only very simplistic ideas about how to express negative feelings. Consequently, Step 1 of the TSPB technique involves helping youth identify various emotional expression techniques and then helping them to try these out. We recommend brainstorming with young clients about specific methods for expressing feelings. The client and counselor should work together (perhaps with a chalk/grease board or large drawing pad), generating a list of expressive strategies that might include:
scribbling on a note pad with a black marker
drawing an angry, ugly picture
punching or kicking a large pillow
jumping up and down really hard
writing a nasty note to someone (but not delivering it)
grimacing and making various angry faces into a mirror
using words, perhaps even yelling if appropriate, to express specific feelings.
The expressive procedures listed above are easier for young clients to learn and understand when counselors actively model affective expression or assist clients in their affective expression. It’s especially important to model emotional expression when clients are inhibited or unsure about how to express themselves. Again, we recommend engaging in affective expression jointly with clients. We’ve had particular success making facial grimaces into a mirror. (Young clients often become entertained when engaging in this task with their counselor.) The optimal time for shifting to Step 2 in the TSPB technique is when clients have just begun to show a slight change in affect. (Often this occurs as a result of the counselor joining the client in expressing anger or sadness or general nastiness.)
Note: If a young client is unresponsive to Step 1 of the TSPB technique, don’t move to Step 2. Instead, an alternative mood-changing strategy should be considered (e.g., perhaps food and mood or the personal note). Be careful to simply reflect what you see. “Seems like you aren’t feeling like expressing those yucky feelings right now. Hey, that’s okay. I can show you this trick some other day. Want some gum?”
Step 2: Think a new thought (or engage in a new behavior). This step focuses on Mosak’s pushbutton approach (Mosak, 1985). It’s designed to demonstrate to the client that emotions are linked to thoughts. Step 2 is illustrated in the following dialogue (an extension of the previous case example with John and Sam):
JSF: Did you know you can change your mood just by thinking different thoughts? When you think certain things it’s like pushing a button in your brain and the things you think start making you feel certain ways. Let’s try it. Tell me the funniest thing that happened to you this week.
S: Yesterday in math, my friend Todd farted (client smiles and laughs).
JSF: (Smiles and laughs back) Really! I bet people really laughed. In fact, I can see it makes you laugh just thinking about it. Way back when I was in school I had a friend who did that all the time.
The content of what young people consider funny may not seem particularly funny to adults. Nonetheless, it’s crucial to be interested and entertained—welcoming the challenge to empathically see the situation from the 13-year-old perspective. It’s also important to stay with and build on the mood shift, asking for additional humorous thoughts, favorite jokes, or recent events. With clients who respond well, counselors can pursue further experimentation with various affective states (e.g., “Tell me about a sad [or scary, or surprising] experience”).
In some cases, young clients may be unable to generate a funny story or a funny memory. This may be an indicator of depression, as depressed clients often report greater difficulty recalling positive or happy events (Weerasekera, Linder, Greenberg, & Watson, 2001). Consequently, it may be necessary for the counselor to generate a funny statement.
S: I can’t think of anything funny.
JSF: Really? Well, keep trying . . . I’ll try too (therapist and client sit together in silence for about 20 seconds, trying to come up with a positive thought or memory).
JSF: Got anything yet?
JSF: Okay, I think I’ve got one. Actually, this is a joke. What do you call it when 100 rabbits standing in a row all take one step backwards?
JSF: (repeats the question)
S: I don’t know. I hate rabbits.
JSF: Yeah. Well, you call it a receding hare line. Get it?
S: Like rabbits are called hares?
JSF: Yup. It’s mostly funny to old guys like me. (JSF holds up his own “hare line”)
S: That’s totally stupid, man (smiling despite himself). I’m gonna get a buzz cut pretty soon.
When you tell a joke or a funny story, it can help clients reciprocate with their own stories. You can also use teasing riddles, puns, and word games if you’re comfortable with them.
We have two additional comments for counselors who might choose to use a teasing riddle which the client may get wrong. First, you should use teasing riddles only when a strong therapeutic relationship is established; otherwise, your client may interpret teasing negatively. Second, because preteen and teen clients often love to tease, you must be prepared to be teased back (i.e., young clients may generate a teasing riddle in response to a your teasing riddle).
Finally, counselors need to be sensitive to young clients who are unable to generate a positive thought or story, even after having heard an example or two. If a young client is unable to generate a funny thought, it’s important for you to remain positive and encouraging. For example:
JSF: You know what. There are some days when I can’t think of any funny stories either. I’m sure you’ll be able to tell me something funny next time. Today I was able to think of some funny stuff . . . next time we can both give it a try again if you want.
Occasionally, young clients won’t be able to generate alternative thoughts or they won’t understand how the pushbutton technique works. In such cases, the counselor can focus more explicitly on changing mood through changing behaviors. This involves getting out a sheet of paper and mutually generating a list of actions that the client can take—when he or she feels like it—to improve mood.
Sometimes depressed young clients will need to borrow from your positive thoughts, affect, and ideas because they aren’t able to generate their own positive thoughts and feelings. If so, the TSPB technique should be discontinued for that particular session. The process of TSPB requires completion of each step before continuing on to the next step.
Step 3: Spread the good mood. Step 3 of this procedure involves teaching about the contagion quality of mood states. Teaching clients about contagious moods accomplishes two goals. First, it provides them with further general education about their emotional life. Second, if they complete the assignment associated with this activity, they may be able to have a positive effect on another person’s mood:
JSF: I want to tell you another interesting thing about moods. They’re contagious. Do you know what contagious means? It means that you can catch them from being around other people who are in bad moods or good moods. Like when you got here. I noticed your mom was in a pretty bad mood too. It made me wonder, did you catch the bad mood from her or did she catch it from you? Anyway, now you seem to be in a much better mood. And so I was wondering, do you think you can make your mom “catch” your good mood?
S: Oh yeah. I know my mom pretty well. All I have to do is tell her I love her and she’ll get all mushy and stuff.
JSF: So, do you love her?
S: Yeah, I guess so. She really bugs me sometimes though, you know what I mean?
JSF: I think so. Sometimes it’s especially easy for people who love each other to bug each other. And parents can be especially good at bugging their kids. Not on purpose, but they bug you anyway.
S: You can say that again. She’s a total bugging expert.
JSF: But you did say you love her, right?
JSF: So if you told her “I love you, Mom,” it would be the truth, right?
JSF: And you think that would put her in a better mood too, right?
S: No duh, man. She’d love it.
JSF: So, now that you’re in a better mood, maybe you should just tell her you love her and spread the good mood. You could even tell her something like: “Dude, Mom, you really bug me sometimes, but I love you.”
S: Okay. I could do that.
It’s obvious that Sam knows at least one way to have a positive influence on his mother’s mood, but he’s reluctant to use the “I love you” approach. In this situation it would be useful for Sam to explore alternative methods for having a positive effect on his mother’s mood.
Although some observers of this therapy interaction may think the counselor is just teaching Sam emotional manipulation techniques, we believe that viewpoint makes a strong negative assumption about Sam and his family. Our position is that successful families (and successful marriages) include liberal doses of positive interaction (Gottman et al., 1995). Consequently, unless we believe Sam is an exceptionally manipulative boy (i.e., he has a conduct disorder diagnosis), we feel fine about reminding him of ways to share positive (and truthful) feelings with his mother.
To spread a good mood requires a certain amount of empathic perspective taking. Often, youth are more able to generate empathic responses and to initiate positive interactions with their parents (or siblings, teachers, etc.) after they’ve achieved an improved mood state and a concomitant increased sense of self-control. This is consistent with social–psychological literature suggesting that positive moods increase the likelihood of prosocial or altruistic behavior (Isen, 1987). Because of developmental issues associated with being young, it’s sometimes helpful to introduce the idea of changing other people’s moods as a challenge (Church, 1994). “I wonder if you have the idea down well enough to actually try and change your mom’s mood.”
Once in a while, when using this technique, we’ve had the pleasure of witnessing some very surprised parents. One 12-year-old girl asked to go out in the waiting room to tell her grandmother that she was going to rake the lawn when they got home (something Grandma very much wanted and needed). Grandma looked positively stunned for minute, but then a huge smile spread across her face. The girl skipped around the office saying, “See. I can do it. I can change her mood.”
One 14-year-old boy thought a few minutes, then brought his mom into the office and said “Now Mom, I want you to think of how you would feel if I agree to clear the table and wash the dishes without you reminding me for a week.” Mom looked a bit surprised, but admitted she felt good at the thought, whereupon I (John) gave the boy a thumbs up signal and said, “Well done.”
At this point, readers should beware that although we’re describing a Three-Step technique, we’ve now moved to Step 4. We do this intentionally with young clients to make the point that whenever we’re working with or talking about emotions, surprising things can happen.
In keeping with the learn-do-teach model, we ask our young clients to teach the TSPB procedure to another person after they learn it in therapy. One girl successfully taught her younger brother the method when he was in a negative mood during a family hike. By teaching the technique to her brother, she achieved an especially empowering experience; she began to view herself as having increased control over her and her family’s emotional states.
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