Tag Archives: Psychotherapy

Suicide Assessment and Intervention

Suicide Assessment and Intervention for the 21st Century

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This past year, Alexander Street Press has been filming and producing a number of Ted-like talks focusing on counseling and psychotherapy. These are 15 minute talks, followed by a short Q & A on the topic. Below is a transcript from a talk I gave this summer in their studio at Governor’s State University in Chicago. I’m posting this talk in honor of National Suicide Prevention Day. This talk, and another couple dozen talks, should be available later this year or early next year from Alexander Street Press: http://search.alexanderstreet.com/counseling-therapy

Here’s the transcript:

Ironically I usually feel happy when I’m asked to do a talk on suicide and then I start with great confidence. I think it’s because suicide is such an extremely important and stressful issue for mental health professionals. But once I dive into the content, I remember how difficult this topic is. During one public presentation a therapist-friend of mine walked out because, as he told me later, the content was hitting too close to home. So please, as you listen, take care of yourself and talk to friends and colleagues for support.

To be perfectly honest, I DON’T REALLY LIKE to talk about suicide, but I think it’s VERY IMPORTANT that we do so directly . . . with each other and with our clients . . . and so here we go.

Death by suicide is pretty rare. Every year, only about 1 in 10,000 Americans commit suicide.

Despite its low frequency, suicide is still a major social problem that affects nearly everyone in one way or another. Over the years you’ve probably heard of many famous people who died by suicide. Marilyn Monroe and Kurt Cobain are two prime examples.

Perhaps even more important is the problem of suicide attempts. About 10% of the human population has attempted suicide and about 20% report struggling with suicidal thoughts and impulses. In surveys of high school students about 50% report “thinking about suicide.”

To summarize what we know about suicide base rates we can say:
I. Death by suicide is infrequent
II. Suicide attempts are NOT infrequent. In fact, many people attempt suicide and then go on to lead happy and meaningful lives
III. Suicide ideation (thoughts) are common
IV. And this is what makes suicide prediction very difficult, because it occurs so infrequently, but this is also what makes suicide prevention very necessary.

In 1991, I worked with a young man who ended up killing himself. This was a tragedy and I remember feeling that gut-wrenching guilt and regret that really stays with you a long time. Afterwards, my consultation group quizzed me and declared that I had done what I could, following all the standard and customary professional suicide assessment procedures. But in my mind and in my heart, then and now, I know I could have done better.

You see back in 1991, professionals (and the public) lived by a big suicide-related myth. We generally viewed suicidal thoughts as DEVIANCE. And so, when clients talked of suicide, it was our job to take action to assess and intervene to eliminate the suicidal thoughts.

This way of thinking about suicide is unhelpful. It creates distance between the professional therapist and his or her client; it also takes power away from clients. And so it’s NOW TIME FOR US TO BUST THE BIG SUICIDE MYTH.

NO LONGER should we consider suicidal thoughts and impulses simply as SIGNS OF DEVIANCE. Instead, we should view suicidal thoughts and impulses as normal signs of human distress. THIS IS THE NEW – and the more accurate – REALITY

Let’s take a minute now to contrast traditional and contemporary or post-modern suicide assessment and intervention approaches. The old Narrative is sort of a checklist approach where we emphasize risk factors, diagnostic interviewing, and no-suicide contracts. The New Narrative is different; it involves looking for protective factors, client strengths, normalizing suicide ideation, and initiating a collaborative safety plan.

This is what I wish I’d understood back in 1991. And so I’d like to be more specific about what I would have done differently and what all mental health professionals should be doing differently.
I wish I had asked more about his protective factors. Protective factors are things like reasons for living and so I wish I’d been more courageous in sitting with him and exploring the reasons why he wanted to live. I wish I’d asked him, over and over, what would or what could help him want to live.

I wish I had asked him more directly about what would help him control his suicide impulses. I would have asked him who he wanted around to help him. I would have lingered on this and asked, who else, what if that person can’t be there, who else would be your next choice to turn to for help.

One of the big changes in the suicide intervention field is that we no longer ask clients to sign No-Suicide contracts. Instead, we work to collaboratively develop a safety plan. As a part of this different focus, I wish I had clearly and unequivocally said to him: “I WANT YOU TO LIVE.” This is different than arguing with clients about their right or need to commit suicide. We should never argue against suicide because that can activate client resistance and make the act even more likely. But the language, “I WANT YOU TO LIVE” is just a self-disclosure and is therefore unarguable. It clearly communicates the intent to help.

Overall, I should have been MORE BALANCED and asked about what my client was doing when his depressive symptoms were gone. I should have asked about what he hoped for today and tomorrow and into the future. I should have asked him more about what brought a little light into his darkness. We should have brainstormed how to bring the light in when he was feeling down.
One problem with the old No-Suicide contracts is that clients sometimes viewed them as designed more to protect the counselor than the client. Obviously this is backward and not the sort of message we want to give clients who are suicidal. And so no-suicide contracts are out . . . and collaborative safety plans are in. What this requires is for counselors to dig in deeper and explore together specifically what the client is willing to do if the suicidal impulses come.

And now, because this talk is all about balancing negative and positive and I want to give an example of two suicide interventions, I’m going to share a positive story about suicide. Maybe I shouldn’t have said that, because now you already know there’s a happy ending. Oh well. Having a happy ending story is a good thing when you’re doing a suicide presentation.

About 5pm one evening I was about to head home and got a call from an alcohol and drug prevention organization across the street from where I was working. A suicidal 16-year-old had suddenly walked into their agency and they had no professional therapists on staff. They asked me to come over and help. I went right over and sat down with the girl in their lobby. We talked a while and she said she had left the local psychiatric unit and was planning to kill herself by jumping off a bridge about a quarter mile away. I listened and then began a specific suicide intervention developed by Edwin Shneidman, well-known as the father of suicidology. I said something like, “So you want to kill yourself. That’s one option, but let’s look at some others.” She said she wasn’t interested in any other options, but I got out a sheet of paper and wrote down “Kill myself” in the left hand column and asked her for other options. She said, “I don’t have any other options.” I said, how about going back to the hospital?” She said, “No way.” I said, that’s okay, we’re just making a list. Got any ideas? She said nothing. I said, “How about some family therapy?” She said, “No way.” I said, “Okay. I’ll write it down anyway because we’re just making a list. You don’t have to do any of these things.” Over time, I came up with about eight ideas of what she might do instead of kill herself, but she hadn’t come up with any. But the purpose of the intervention I was using was to address what Shneidman calls mental constriction. Mental constriction occurs when suicidal individuals are feeling so stressed and miserable that all they can consider is continued misery or death by suicide. With this intervention, I was working on opening up her mental blinders so she could see and consider alternatives to suicide. And so despite the fact that she didn’t generate or endorse any of the alternatives, I handed her the sheet of paper and asked her to rank order her preferences. And somewhat to my surprise, she ranked “Kill myself” as number three. There were two other options she preferred over suicide. I went for that and asked how I could help her get family therapy, which was her first choice. She re-escalated and headed out the door and down the street toward the bridge. I followed and walked with her and talked on and on about how “I want you to live.” She eventually got to the corner where we would cross the street to get on the bridge and I said I was stopping there. She stopped too and I reached out and grabbed her hand. She pulled back and yelled at me for touching her. Then I tried another specific suicide intervention, called Neodissociation. I said, “I know somewhere inside there’s a part of you that wants to live a happy and healthy life. Please, I want that part of you to just reach out and take my hand and walk with me back to the office so we can get you the help you deserve. She stared at me, reached out, took my hand, and then walked back to the office where I called the police and they took her back to the hospital.

[Insert big sigh here].

About two months later, I got a card from her that read, “The only bridges in my life now are bridges to health and happiness.” Now that’s a pretty good ending, but there’s more.

About six months later I asked her therapist if he thought it would be okay for me to interview her about what she thought was most helpful to her in choosing life over suicide. He asked her and then she came to my office for a short video interview. I remember asking her what was most helpful and she said she had a great student nurse at the hospital who was “Fresh” and genuine and that had helped a lot. Then I asked her what had helped her come with me on that first night we’d met. She said, “I’m not sure.” Eager for affirmation, I asked if it was when I used the neodissociation technique and she responded, “No way. That was really stupid.” Then she spontaneously said that she thought it was the look on my face, when I stopped and said I would go no further. She said that—in that moment—I looked like I really cared.

And so that’s the suicide story I prefer to remember.

Speaking of remembering, let’s review the main points.

In summary, there are three main modifications to the traditional approach, which I sometimes call the NEW MANTRA.
• There’s NO MORE BIG MYTH and so we normalize suicidal thoughts and impulses to counter our client’s feelings of deviance; they already feel deviant enough, we don’t need to add to that.
• Collaborate with clients. . . and be sure to do so from a place of genuine caring. It’s okay to say: “I WANT YOU TO LIVE” while collaboratively developing a safety plan.
• Use strength-based questioning, focusing on hope instead of hopelessness; meaning instead of meaninglessness.
• And of course, as always, like all good professionals, consult and document.

I’d like to end with a comment on self-care. As you can see in the final photo, my two daughters are engaged in what appears to be rather bizarre human behavior. I like to think of this as the one daughter performing a helpful “Pit-Check” for the other. We all need that and we especially need that when we’re working with clients who are suicidal. We need to keep talking and asking, “How am I doing?” We need to check up and check in with our colleagues and take very good care of ourselves because although the work we’re doing is essential . . . it can also be terribly stressful to face alone.

This reminds me of what another client once said to me. He said: The mind is a terrible place to go . . . alone . . . which is why we should keep on talking—directly to each other and to our clients—about suicide and suicide prevention.

Thanks for listening.

Counseling and Psychotherapy Theory and Practice

Behavioral Activation Therapy: Let’s Just Skip the Cognitions

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This is a short excerpt from the text: Counseling and Psychotherapy Theories in Context and Practice

It describes a research-based behavioral approach to counseling and psychotherapy.

Over half a century ago, Skinner suggested that depression was caused by an interruption of healthy behavioral activities that had previously been maintained through positive reinforcement. Later, this idea was expanded based on the initial work of Ferster (1973) and Lewinsohn (1974; Lewinsohn & Libet, 1972). The focus was on observations that:

“. . . depressed individuals find fewer activities pleasant, engage in pleasant activities less frequently, and obtain therefore less positive reinforcement than other individuals.” (Cuijpers, van Straten, & Warmerdam, 2007, p. 319)

From the behavioral perspective, the thinking goes like this:
1.   Observation: Individuals experiencing depression engage in fewer pleasant activities and obtain less daily positive reinforcement.

2.   Hypothesis: Individuals with depressive symptoms might improve or recover if they change their behavior (while not paying any attention to their thoughts or feelings associated with depression).

Like the good scientists they are, behavior therapists have tested this hypothesis and found that behavior change—all by itself—can produce positive treatment outcomes among clients with depression. The main point is to get clients with depressive symptoms to change their behavior patterns so they engage in more pleasant activities and experience more positive reinforcement
Originally, behavioral activation was referred to as activity scheduling and used as a component of various cognitive and behavioral treatments for depression (A. T. Beck, Rush, Shaw, & Emery, 1979; Lewinsohn, Steinmetz, Antonuccio, & Teri, 1984). During this time activity scheduling was viewed as one piece or part of an overall cognitive behavior treatment (CBT) for depression.
However, in 1996, Jacobson and colleagues conducted a dismantling study on CBT for depression. They compared the whole CBT package with activity scheduling (which they referred to as behavioral activation), with behavioral activation (BA) only, and with CBT for automatic thoughts only. Somewhat surprisingly, BA by itself was equivalent to the other treatment components—even at two-year follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998; Jacobson et al., 1996).

As is often the case, this exciting research finding stimulated further exploration and research associated with behavioral activation. In particular, two separate research teams developed treatment manuals focusing on behavioral activation. Jacobson and colleagues (Jacobson, Martell, & Dimidjian, 2001) developed an expanded BA protocol and Lejuez, Hopko, Hopko, and McNeil (2001) developed a brief (12 session) behavioral activation treatment for depression (BATD) manual and a more recent 10 session revised manual (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011).

Implementation of the BATD protocol is described in a short vignette later in the behavioral theory and therapy chapter in the text: Counseling and Psychotherapy Theories in Context and Practice by John and Rita Sommers-Flanagan. See: http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470617934.html

Or, on Amazon: http://www.amazon.com/John-Sommers-Flanagan/e/B0030LK6NM/ref=ntt_dp_epwbk_1

Several people engaging in behavioral activation therapy at a wedding.

Dancing

 

Divorce, Parenting

Parenting Consultations with Divorced, Divorcing, and Never-Married Parents

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Working with parents who are divorced, divorcing, or living separately can be both challenging and gratifying. In this excerpt from “How to Listen so Parents will Talk and Talk so Parents will Listen” we discuss some key issues and provide a case example. The main purpose of this post is to stimulate your thinking about working with this unique and interesting population of parents.

Here’s the excerpt:

Divorce will probably always be a controversial and conflict-laden issue within our society. In part, this is due to moral issues associated with divorce, but it is also due to the many knotty practical issues divorced parents frequently face.

Divorce Polemics

Divorce and single-parenting choices still carry stigma and so parents will be monitoring for any judgments you might have about them. You may have very strong opinions about divorce or about people choosing to adopt or bear children while single. If this is something you can’t put aside and be nonjudgmental about, it’s best to put your views in your informed consent so parents know this explicitly about your practice. In most cases, professionals have values and beliefs they can keep in check while working directly with people who make choices far different than the professional might have made. For instance, you might firmly believe that all children should be born into a two-parent family with parents who are married and committed to the family, but you might still be able to be very helpful to a single gay parent who adopted a 10-year-old disabled foster child.

Because they’ve sometimes faced moral and religious judgments, divorced, divorcing, and never-married parents have substantial needs for support and education. Consequently, you should prepare yourself to provide that education and support. Their parenting challenges can be particularly acute and confusing.

The issue for practitioners working with parents is to avoid laying blame and guilt on parents for divorcing (generally, they already feel guilty about how their divorce might be affecting their children). Instead, your role is to help divorced, divorcing, or never-married parents manage their difficult parenting situations more effectively. What we need to offer is (1) emotional support for divorce- and post-divorce-related stress and conflict; and (2) clear information on specific behaviors parents can engage in or avoid to help their children adjust to divorce.

Providing Support and Educational Information
Most divorcing and recently divorced parents are in substantial distress and so parents and need comfort, support, and information. Consequently, we recommend talking with parents about divorce in a way that’s empathic and educational. In the following case, a father with three children has come for help in planning to tell the children. His children are 4, 6, and 8 years old.

         Case: Talking about Divorce

PARENT: I’m really worried about how to talk with my kids about the divorce. I can’t get the right words around it. I know I’m supposed to say something reassuring like, “Your mom and I love each other, but it just hasn’t worked out and so that’s why I’m moving out because it will be best for us to live separately.” But then I worry that maybe my kids will think even though I love them now, it might not “work out” either and then I’ll end up leaving them, too.

CONSULTANT: This is tough. I respect how much thought you’ve given this. Even though the differences between you and your wife make it too hard to live together, it’s extremely hard to leave the home and torturous to talk with your kids about it.

PARENT: That’s for sure.

CONSULTANT: I can see you love your children very much and it feels really important to talk with them about the upcoming divorce using words that won’t scare them too much and that will help them know you and your wife tried, but you have now decided that the divorce is for the best. But before we do that, I have a different piece of advice.

PARENT: What’s that?

CONSULTANT: You should plan to have more than one divorce talk with your kids. I know you want to do this right and that’s great. But the good news and the bad news is that you’ll need to have this conversation many times. As your children grow older, they’ll have different questions. It’s your job to tell them you love them and to explain things in words they’ll understand, but not to tell them too much. There’s no guarantee they’ll understand this perfectly and so it may relieve pressure for you to know you’ll get other chances. Some people like to think of it like having a sex-talk. Kids will have different questions about sex at different ages and so parents shouldn’t have just one sex-talk. You need to be ready to have a sex-talk at any time as your child is growing up. The same is true for talks about divorce. You need to be ready to talk about it now and whenever your kids or you need to talk in the future. I’ve got a great tip sheet for parents going through divorce and I’d like to go over that with you, too. [See Appendix B, Tip Sheet 10: Ten Tips for Parenting through Divorce.]

In this situation, the family’s educational needs are significant, so the practitioner will probably offer the father a tip sheet, additional reading materials, and a recommendation to attend a group class on divorce and shared parenting.

It can be difficult for divorcing parents to talk with their children without blaming the other parent. This can be either blatant or subtle. We recall one parent who insisted he had the right to call his former spouse “The Whore” in front of the children “because it was the truth.” In these extreme cases, we’ve used radical acceptance to listen empathically to the emotional pain underlying this extreme perspective and then slowly and gently help the parent to understand that “telling the truth” to the children should focus on telling your personal truth and not on the other parent’s behavior. Although it can be difficult for divorced or divorcing parents to hear educational messages over the din of their emotional pain, it’s the practitioner’s job to empathically and patiently deliver the message. Usually divorced and divorcing parents eventually see that criticizing or blaming the other parent can be damaging to their children.

More information on this and other topics related to working with parents is available on this blogsite (see the Tip Sheets) and in the “How to Listen so Parents can Talk” book.

See: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_9?s=books&ie=UTF8&qid=1403469599&sr=1-9

 

Boys and Men, Counseling and Psychotherapy Theory and Practice, Personal Reflections

What Kind of a Man Attends the 4th National Psychotherapy with Men Conference?

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Several years ago a former student caught up with me in the hall outside my office in the College of Education at the University of Montana. He had taken an Intro to Psychology course from me way back in 1982. He re-introduced himself, complimented me on my teaching from three decades previously, and then, glancing at my name on the door, asked, “What kind of a man hyphenates his last name?”

I was speechless (which doesn’t happen all that often). He had just told me of his divorce; he had marveled at me being married for 25 years; and yet there it was, a small-dose of straight on masculine-shaming.

I said what most of us probably say when questioned about our masculinity.

I said nothing.

In retrospect, I wish I’d said: “I hyphenated my name because I’m the kind of man who wants to stay married and have a real partnership with his wife.” Hmm. That might have been over-the-top.
I didn’t have a balanced answer then and I’m not sure I have a good one now. But, how about cutting to the chase and meeting his question with one of my own?

“What kind of a man questions another man about his masculinity?”

That might have been fun, but obviously not perfect. And that’s the point; it can be difficult to find the right words in response to comments on our masculinity.

This past Saturday I had the privilege of embracing all dimensions of my humanity, without needing to worry about sideways—or straight on—masculinity comments. That’s because I had the good fortune of attending the 4th National Psychotherapy with Men Conference. Of course, my comfort might have been because the chief conference organizer, Matt Englar-Carlson, a faculty member in the Department of Counseling at Cal State Fullerton, is also a hyphenator. But more likely it was because this particular conference was all about acceptance, inclusion, listening, understanding, learning . . . and most of all CONNECTION. Masculine shaming was nowhere in the room.

The conference organizers, Englar-Carlson, David Shepard, and Rebekah Smart, set the tone for understanding and inclusiveness in their opening comments. The opening keynote followed and it was BY A WOMAN . . . which this leads me to back to my masculine-shaming theme for today:

“What kind of a MEN AND MASCULINITY organization sponsors a conference on psychotherapy with men and then has an opening keynote speech BY A WOMAN?”

Answer: “The kind of organization populated by people who have the good judgment to be very interested in listening to and understanding women’s perspectives.”

And so we all got to listen to—not just any woman (although that would have been fine too, because the conference wasn’t about status)—but the renowned Judith Jordan, author of many books and co-director of the Jean Baker Miller Institute. How cool is that?

After Jordan explored how we can raise boys to be competent and connected men, we scattered to different break-out sessions. As my adolescent clients would say, this sucked because it’s hard to make hard choices. My principle regret of the whole conference was that even though I have two last names, there’s still only one of me and so I couldn’t attend EVERY SESSION, but instead had make choices. And although I was perfectly happy to start my break-out experiences listening to Christopher Kilmartin, professor of psychology at the University of Mary Washington, as Irvin Yalom would say, it meant the death of the rest of my choices.

But seriously . . . here’s the important question: “What kind of a man accepts a faculty position at an institution named THE UNIVERSITY OF MARY WASHINGTON?”

Answer: “The same kind of man who gets asked to spend a year teaching sexual assault prevention at the Air Force Academy.” Now that’s a pretty good answer.

Kilmartin was awesome (just ask my wife, because I’ve been quoting him all week). But being at his break-out session made me miss the amazing Jon Carlson who might be the kindest, gentlest, and most humble person I know with hundreds of professional publications, video productions, and spare time to raise five children (two adopted) including the hyphenated conference organizer, who happens to have full professor status despite looking like he just shaved for the first time last week.

Naturally, the psychotherapy with men conference lunch had a vegetarian option (at this point I should also mention the Starbucks coffee and whole wheat bagels in the morning and the Panera coffee and cookies in the afternoon). Right after lunch, we gathered to listen to Fredric Rabinowitz, the afternoon keynote. Rabinowitz, who also happens to play tournament poker, talked about Deepening Psychotherapy with Men. He emphasized that, for men, there’s a substantial vocabulary about defenses, but not Department of Connection. For the past 20+ years he has helped men go deep and express their pain and loss in ways that are (surprise!) contrary to how society expects men to express their pain and loss. Unfortunately, Rabinowitz had to miss an annual fancy poker tournament to attend the conference . . . which leads to the obvious question:

“What kind of a man misses a poker tournament to talk with a bunch of sensitive psychotherapy-types?”

Answer: “A pretty cool dude who knows his priorities.”

After Rabinowitz’s keynote, there were more decisions. In my program I had circled presentations by David Shepard and Michele Harway as well as Chris Liang. But I should confess here-and-now that I got slightly intoxicated with Panera coffee and cookies and ended up wandering into the wrong room with three Canadian presenters who were talking about how to help men transition from military to civilian life. It might have partially been the coffee, but the Three Canadians ROCKED MY WORLD . . . which begs the question:

“What kind of a man gets his world rocked by Three Canadians?”

Answer: “The kind of man who recognizes they have such fabulous clinical skills and compassion and cleverness that it makes him wish he was born and raised in Vancouver, B.C. instead of Vancouver, Washington (not that there’s anything wrong with Vancouver, WA).”

After my Canadian experience I staggered into Mark Stevens’s presentation on Engaging Men in the Process of Psychotherapy. Stevens showed photos of little boys and asked us to remember that ALL OF OUR MALE CLIENTS were once sensitive boys (not little men). He urged us to engage men slowly, but to not judge or underestimate them in ways that minimize or shrink their humanity. This was awesome, but I have to ask:

“What kind of a man shows photos of little boys during a professional presentation?”

Answer: “The kind of man who understands how to work effectively with men.”

At this conference you didn’t need a hyphenated name and you didn’t need an un-hyphenated name, because there was no shaming either way. There was just acceptance; acceptance of being scared boys and scared girls who are doing the best we can to openly affirm and connect with each other. And these connections reached across races, to the transgendered, to the women, and even to graduate students. If you’re interested in this sort of thing (and I think you should be), you should check out Division 51 of the American Psychological Association at: http://www.division51.org/

BTW, at the post-conference social I got to meet lore m. dickey, who presented earlier in the day on Affirmative Practice with Transgender Clients. He immediately shared with me that he is a female to male transsexual. That’s the sort of openness and connection you get at the Psychotherapy with Men conference. But I’m sure you know this leads me to another purposely masculinity-shaming question.

“What kind of a man chooses to go through a female to male transgender process?”

“The kind of a man who has achieved clarity about his male identity.”

The day ended with me hanging out with the Three Canadians—whom I should name here (Marvin Westwood, David Kuhl, and Duncan Shields). They welcomed me to their table at the social time where we engaged in an extended international mutual appreciation festival. You should really look them up.

All this brings me to my final question:

“What kind of a man writes an fluffy, complimentary, and sycophantic blog about the 4th National Psychotherapy with Men Conference?”

Answer: “The kind of man who wants to offer the conference organizers and participants the thanks and praise they deserve.”

 

Uncategorized

Upcoming Webinar: Engaging and Treating Youth with ODD and CD

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Tomorrow at noon Mountain time I’ll be doing a one-hour webinar titled: Engaging and Treating Youth with Oppositional Defiant Disorder and Conduct Disorder (and their Parents). This webinar is hosted by Western Montana Addictions Services. The webinar link for Tuesday, June 10th at noon (MST) is:

https://sas.elluminate.com/m.jnlp?sid=2008093&username=&password=M.5473E398E968F03FF120D04D57D5CF
Conference call line and pin: 571-392-7703 PIN: 832 106 441 879

Join in if you can. I’ll post the powerpoints for the webinar later today or tomorrow.

Happy Monday.

IMG_3098

 

Counseling and Psychotherapy Theory and Practice, Therapy with Adolescents, Tough Kids Cool Counseling

Handling Termination in Counseling and Psychotherapy

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It’s that time of the year (at most colleges and universities) when those of us doing and supervising counseling and psychotherapy should be thinking about how to handle termination. Well, actually we should have been thinking about it before, but if not then, now is good.

Anyway, I just sent the following termination checklist out to my MA and Doc students here at U of MT and thought this could be helpful for others, so here it is. Keep in mind that it was written for working with youth, but can be modified to stimulate your thinking about termination with whatever population with which you work.

Termination Content Checklist

[Adapted from Sommers-Flanagan, J., and Sommers-Flanagan, R., (2007).
Tough Kids, Cool Counseling: User-Friendly Approaches with Challenging Youth.
Alexandria, VA: American Counseling Association]

The following termination content checklist may be helpful for you as you plan for counseling or plan for termination. Keep in mind that this is not a comprehensive checklist that you MUST complete at the end of counseling. Also, keep in mind that the sample statements are just samples and that you should find your own words for expressing these (or similar) things. The point is that this is a guide to help you think about termination—even though some of the details will be different for you and your client(s).

_____ 1. At the outset and throughout counseling, the counselor identifies progress toward termination (e.g., “Before our meeting today, I noticed we have 4 more sessions left,” or “You are doing so well at home, at school, and with your friends. . . let’s talk about how much longer you’ll want or need to come for counseling”).
_____ 2. The counselor reminisces about early sessions or the first time counselor and client met. For example: “I remember something you said when we first met, you said: ‘there’s no way in hell I’m gonna talk with you about anything important.’ Remember that? I have it right here in my notes. You were sure excited about coming for counseling” (said with empathic sarcasm).
_____ 3. The counselor identifies positive behavior, attitude, and/or emotional changes. This is part of the process of providing feedback regarding problem resolution and goal attainment: “I’ve noticed something about you that has changed. It used to be that you wouldn’t let adults get chummy with you. And you wouldn’t accept compliments from adults. Now, from what you and your parents tell me and from how you act in here, it’s obvious that you give adults a chance. You aren’t always automatically nasty to every adult you see. I think that’s nice.”
_____ 4. Acknowledge that the relationship is ending with counseling termination: “Next session will be our last session. I guess there’s a chance we might see each other sometime, at the mall or somewhere. If we see each other, I hope it’s okay for us to say hello. But I want you to know that I’ll wait for you to say hello first. And of course, I won’t say anything about you having been in counseling.”
_____ 5. Identify a positive personal attribute that you noticed during counseling. This should be a personal characteristic separate from goals the client may have attained: “From the beginning I’ve always enjoyed your sense of humor. You’re really creative and really funny, but you can be serious too. Thanks for letting me see both those sides. It took courage for you to seriously tell me how you really feel about your mom.”
_____ 6. If there’s unfinished business (and there always will be) provide encouragement for continued work and personal growth: “Of course, your life isn’t perfect, but I have confidence that you’ll keep working on communicating well with your sister and those other things we’ve been talking about.” You may want to explicitly describe how your client doesn’t “need” counseling, but that continued counseling or counseling in the future might be helpful: “You know some people come to counseling to work on big problems; other people come because they find counseling can be useful and help them move toward personal growth or greater awareness; and other people just like counseling. You might decide you want to continue in counseling or start up again for any of these reasons.”
_____ 7. Provide opportunities for feedback to you: “I’d like to hear from you. What did you think was most helpful about coming to counseling? What did you think was least helpful?” You can add to this any genuine statements about things you wish you’d done differently as long as it’s not based on new insights. For example, if your client got angry for you for misunderstanding something and this was processed earlier, you might say: “And of course I wish I had heard you correctly and understood you the first time around on that [issue], but I’m glad we were able to talk through it and keep working together.”
_____ 8. If it’s possible, let the client know that he or she may return for counseling in the future: “I hope you know you can come back for a meeting sometime in the future if you want or need to.”
_____ 9. Make a statement about your hope for the client’s positive future: “I’ll be thinking of you and hoping that things work out for the best. Of course, like I said in the beginning, I’m hoping you get what you want out of life, just as long as it’s legal and healthy.”
_____ 10. As needed, listen to and discuss client wishes about continuing counseling forever or client wishes about transforming their relationship with you from one of counselor–client to that of parent–child or friend: “Like you’ve known all along, counseling is kind of weird. It’s not like we’re mom and daughter or aunt and niece. And even though I like you and feel close to you, it isn’t really the same as being friends” (further discussion and processing of feelings follows).

For more information on termination with youth, go to: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_3?s=books&ie=UTF8&qid=1396895008&sr=1-3

 

 

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections

Listening as Meditation on Psychotherapy.net

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Listening in psychotherapy and counseling is partly art and partly science. This week I have the good fortune of having a blog piece I wrote on Listening as Meditation published at psychotherapy.net. You can access this blog piece — and other excellent psychotherapy.net blog pieces — at: http://www.psychotherapy.net/blog

Have an excellent and mindful Wednesday.

John SF

Counseling and Psychotherapy Theory and Practice

How to Use the Six Column CBT Technique

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A Description of the Six Column CBT Technique

In contrast to popular belief, CBT requires counselors to be warm and compassionate. Also, the focus of CBT is on experiential psychoeducation. Aaron Beck emphasized collaborative empiricism. Never forget that term. Collaborative empiricism is the bedrock of good CBT. It emphasizes the process of counselors and clients working together to test the accuracy and usefulness of specific thoughts and behaviors. As a therapeutic process, collaborative empiricism is also central to Person-Centered and Motivational Interviewing approaches. Remember: We want the client to have a central role in determining the usefulness and dysfunctionality of his or her cognitions and behaviors.

The six column technique is simply a procedure that helps clients and counselors organize, explore, and discover how situations, thoughts/beliefs, emotions, behaviors, and emotional/interpersonal/psychological outcomes are inter-related. This is my own particular version of the six column technique. It’s derived from the work of Aaron Beck, Albert Ellis, Judith Beck, and other cognitive behavioral therapists. You can see a short clip of me using this technique at: https://www.youtube.com/watch?v=jfVeeGJHFjA

Here’s a description of the six columns:

Column #1: The Situation

BE THINKING ABOUT LINKING EMOTIONS TO SPECIFIC SITUATIONS

It may be that you’ll begin with whatever emotional distress the client is experiencing or reporting. Or you may begin with thoughts and beliefs that are clearly linked to specific client emotions and behaviors. Or you may begin with the situation or “trigger” for the cognitions and subsequent emotions.

Here’s an example of a situation as reported by a client:

“My in laws are staying in my home     .”

“They’re messy and lazy and I have to pick up after them”

Column #2: Automatic Thoughts and Automatic Behaviors

HELP CLIENTS SEE THAT AUTOMATIC THOUGHTS ARE OFTEN THE BRIDGE BETWEEN SITUATIONS AND EMOTIONS

Here are some examples of the automatic thoughts the clients thinks when she faces the previously described situation:

“They’re old enough to pick up after themselves.”

“Sometimes I stand in front of the television they’re watching to block their view as I pick their stuff up.”

Sometimes if “she” says she’ll do the dishes, I say, “No thanks. I want them to get done in the next two weeks.”

REMEMBER THAT AN EXPLORATION OF YOUR CLIENTS AUTOMATIC THOUGHTS AND BEHAVIORS OFTEN WILL SHED LIGHT ON DEEPER CORE BELIEFS ABOUT THE SELF, THE WORLD, AND THE FUTURE.

Column #3: Emotions and Sensations

SOMETIMES IT IS VERY NATURAL TO START HERE BECAUSE YOUR CLIENT’S EMOTIONS AND SENSATIONS MAY BE A WAY THAT THE MIND AND BODY ARE VOICING HIS OR HER DISTRESS (or you may find the best entry point into the six column technique is somewhere else)

Here are the ratings and descriptions the client provided for column #3:

Anger = 75 (on a 0-100 scale with 0 = totally mellow and 100 = explosive distress)

Discomfort = 75

EMOTIONS AND SENSATIONS MAY BE WHAT IS MOST TROUBLING TO CLIENTS AND THAT’S WHY THEY’RE TYPICALLY RE-EXAMINED IN COLUMN #6: NEW OUTCOMES

Column #4: Helpful Thoughts

HELPFUL THOUGHTS ARE ALSO SOMETIMES REFERRED TO AS “COOL THOUGHTS.” THIS IS ESPECIALLY TRUE WHEN WORKING WITH ANGER AND AGGRESSION BECAUSE COOL THOUGHTS HELP CALM OR COOL OFF THE ANGER AND REDUCE THE POTENTIAL FOR AGGRESSION.

Here are some thoughts that the client identified as helpful. Helpful thoughts are often seen as adaptive or more accurate or more “rational” (which is an Albert Ellis term).

“This is important for my husband.”

“I can see this as a challenge for me to become more direct and assertive.”

“They mean well.”

A WAY OF ASKING ABOUT HELPFUL THOUGHTS IS TO JUST ASK DIRECTLY: WHAT ARE SOME THOUGHTS OR BELIEFS THAT YOU THINK WOULD BE HELPFUL TO YOU IN THIS SITUATION? YOU MAY NEED TO HELP CLIENTS WITH THIS BY PROVIDING EXAMPLES . . . BUT NOT BY TELLING THEM WHAT THEY SHOULD THINK. ENCOURAGE THEM TO FIND THEIR OWN WORDS.

Column #5: Helpful Behaviors

SIMILAR TO THE PRECEDING COLUMN, WE CAN THINK OF BEHAVIORS AS “HOT” OR “COOL” BEHAVIORS. HOT BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS WORSE; COOL BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS BETTER.

Here are some behaviors the clients said she thought might be helpful:

“I could sit down and talk with them about picking up their messes at a regular time.”

“I could ask my husband to talk with them.”

“I could go to a Yoga class two nights a week.”

WHEN IT COMES TO BOTH HELPFUL THOUGHTS AND HELPFUL BEHAVIORS, IT’S USEFUL TO THINK OF THEM AS OCCURRING (A) BEFORE, (B) DURING, OR (c) AFTER THE SITUATION ARISES. SOME BEHAVIORS (E.G., GETTING ENOUGH SLEEP) HELP THE SITUATION AS A PROACTIVE OR PREVENTATIVE ACTION. OTHER BEHAVIORS (E.G., DEEP BREATHING) MAY BE CRUCIAL DURING THE SITUATION. STILL OTHER BEHAVIORS (E.G., VENTING TO A FRIEND OR PROVIDING SELF-REINFORCEMENT) MAY BE HELPFUL AFTER THE SITUATION IS OVER.

Column #6: New Outcomes

AFTER IMPLEMENTING THE HELPFUL COGNITIONS AND HELPFUL BEHAVIORS, IT’S A GOOD IDEA TO RE-EVALUATE THE CLIENT’S EMOTIONS AND SENSATIONS (OR DISTRESS).

In this case, the client provided the following ratings:

Anger = 40

Discomfort = 40

ONE OF THE GOALS OF CBT IS TO REDUCE DISTRESS AND REDUCE SYMPTOMS AND MAKE LIFE A LITTLE BETTER. YOU MAY NOT CREATE VAST IMPROVEMENTS, BUT IMPROVEMENTS ARE IMPROVEMENTS. THIS IS ALSO JUST THE BEGINNING OF CBT (OR WHATEVER APPROACH YOU’RE USING) BECAUSE THE WHOLE POINT IS THAT LIFE IS AN EXPERIMENT AND THAT WE COLLABORATIVELY AND INTERACTIVELY ARE HELPING CLIENTS TRY OUT NEW THOUGHTS AND BEHAVIORS THAT MAY (OR MAY NOT) LEAD TO IMPROVEMENT. AND IF THE IMPROVEMENT ISN’T OPTIMAL . . . THE CBT WAY IS TO GO BACK TO THE BEGINNING AND REWORK THE PROCESS TO SEE IF FURTHER IMPROVEMENTS CAN OCCUR.

CBT Tips

Here are a few tips on how to integrate CBT in your work.

Some counselors or mental health professionals resist using CBT and complain that it’s too sterile or too educational or not focused enough on feelings. Basically, I think this is a cop-out similar to CBT folks who say that person-centered therapy is ineffective. My belief (and I think it’s rational and so it must be (smiley face) is that when mental health professionals don’t understand how to implement a particular approach, they blame the approach rather than admitting their lack of knowledge or skill. Instead, I encourage you to try this six column CBT model, but use it with whatever other model you prefer. In other words, you can be a person-centered CBT person or an existential CBT person . . . especially if you just use this six column technique as a means for exploring and understanding different dimensions of your client’s personal experience.

Goal-setting is essential to counseling. From the CBT perspective, goal-setting is initiated by generating a problem list. However, your IR clients may not have a problem listJ. That’s why you may need to use your excellent active listening skills to help your clients focus in on a distressing emotion. Then you can begin with the distressing or disturbing emotion and build the six columns from there.

Good CBT involves adopting an experimental mindset (never forget collaborative empiricism). All you’re doing is helping your client look at his/her daily experiences and identify patterns. It helps to organize the client’s experience into Situation, Automatic Thoughts/Behaviors, Emotions and Sensations, Helpful (Cool) Thoughts, Helpful (Cool) Behaviors, and New Outcomes. You can explore these common dimensions of human experience collaboratively.

It’s very important to know and remember that giving behavioral assignments can be disastrous. This is part of why a good CBT counselor is better than a technician. If you’re brainstorming possible helpful behaviors, your client (and you) may zero in on a behavior that, if enacted, has a strong possibility of a negative outcome. New behaviors expose clients to risk. The risk may be worth it; but there also may be too much risk.

Avoid asking questions like: “Have you thought about talking directly to your in-laws?” This sort of question implies that your client should talk directly to the in-laws. It’s better to step back and brainstorm behavioral options with your client. Then, emphasize that behavioral goals must always be in the client’s control. Then, after your nice list of behavioral options has been generated, you can look at the different options and engage in “consequential thinking.” In other words, you ask your client to explore the possibilities of what is likely to happen if: “You (the client) directly confront the in-laws about their messy behaviors? “ (See sample six column worksheet).

There are many ways you can get to your client’s underlying core beliefs or cognitive dynamics. For example, you could ask: “What stops you from telling them to pick up after themselves?” The client might respond with a different emotion and new content (e.g., I’m afraid of getting into a conflict). You can pursue this further: “What is it about being in conflict makes it scary?” She might say, “I’m afraid my husband will side with them and leave me.” As a consequence, this conflict is viewed as something she needs to manage independently and gets at a deeper schema: “I must keep the peace and deal with everything or bad things (e.g., abandonment) will happen.” There are two problems with this: (a) If she overfunctions she feels angry and acts passive-aggressively; and (b) there may be truth to this schema/belief. This is why we can’t just push her into being assertive. We must always keep the corrective emotional experience rule in mind. New behavioral opportunities need to be free from the likelihood of re-traumatization.

Clinical Interviewing, Cool Counseling, Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

January is an Excellent Month to Attend Workshops in Cincinnati

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Just in case you’re planning to be in or around the Cincinnati area this weekend, the Greater Cincinnati Counseling Association (GCCA) is offering a day and a half of workshops starting on Friday afternoon, January 10 and two workshops with one of my favorite workshop presenters on Saturday, January 11. Here’s the info:

On Friday, January 10, there are two Ethics workshops to choose from:

2:00-5:15

School Counselor Ethics: Case

Discussions and Current Trends

Tanya Ficklin

Or

2:00-5:15

Ethical and Professional Issues:

Therapeutic Alliance Building and

Ethical Considerations When

Working with Children and

Families

Barbara Mahaffey

On Saturday, January 11, I’m doing two separate ½ day workshops:

Tough Kids, Cool Counseling

John Sommers-Flanagan

Saturday 8:45-12:00

Therapy with adolescents can be immensely frustrating or splendidly gratifying. The truth of this statement is so obvious that the supportive reference, at least according to many adolescents is, “Duh!” In this workshop participants will sharpen their therapy skills by viewing and discussing video clips from actual sessions and participating in live demonstrations. Over 20 specific cognitive, emotional, and constructive therapy techniques will be illustrated and/or demonstrated. Examples include acknowledging reality, informal assessment, the affect bridge, therapist spontaneity, early interpretations, asset flooding, externalizing language, and more. Countertransference and multicultural issues will be highlighted.

Suicide Assessment Interviewing

Saturday 1:00-4:15

John Sommers-Flanagan

Freud once said, “By words one person can make another blissfully happy or drive him to despair.” Ironically, traditional adolescent suicide assessment and intervention procedures overemphasize a pathology-based biomedical model that orients adolescents toward despair. In this workshop suicidal crises are reformulated as normal expressions of human suffering and a specific, positive, and practical approach to adolescent suicide assessment interviewing is described. This contemporary adolescent suicide assessment model has a constructive focus, addresses diversity issues, and integrates differential activation theory and Jobes’s approach to Collaborative Assessment and Management of Suicidality. Specific suicide intervention procedures will be described and reformulated.

You can register for these workshops by phone by calling: 513-688-0092

 

Clinical Interviewing, Therapy with Adolescents, Tough Kids Cool Counseling

The Therapist’s Opening Statement (or Question) with Adolescents

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           Working with adolescents or teenagers is different from working with adults. In this excerpt from a recently published article with Ty Bequette, we briefly focus on how the opening interaction with an adolescent client might look different than an opening interaction with an adult client. This is from: Sommers-Flanagan, J., & Bequette, T. (2013). The initial interview with adolescents. Journal of Contemporary Psychotherapy, 43(1), 13-22.

            When working with adults, therapists often open with a variation of, “What brings you for counseling” or “How can I be of help” (J. Sommers-Flanagan & Sommers-Flanagan, 2012). These openings are ill-fitted for psychotherapy with adolescents because they assume the presence of insight, motivation, and a desire for help—which may or may not be correct.

Based on clinical experience, we recommend opening statements or questions that are 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 invitations that emphasize 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.

Some adolescent clients will respond to an opening like the preceding with a clear goal statement. We’ve had clients state: “I want to be happier.” Although “I want to be happier” is somewhat general, it is a good beginning for parsing out more specific goals with clients.    Other clients will be less clear or less cooperative in response to the invitation to collaborate. When asked to identify goals, some may say, “I don’t know” while others communicate “I don’t care.”

Concession and redirection are potentially helpful with clients who say they don’t care about therapy or about goal-setting. A concession and redirection response might look like this: “That’s okay. You don’t have to care. How about we just talk for a while about whatever you like to do. I’d be interested in hearing about the things you enjoy if you’re okay telling me.” Again, after conceding that the client does not have to care, the preceding response is an invitation to talk about something less threatening. If adolescent clients are willing to talk about something less threatening, psychotherapists then have a chance to listen well, express empathy, and build the positive emotional bond that A. Freud (1946, p. 31) considered a “prerequisite” to effective therapy with young clients.

Some adolescents may be unclear about limits to which psychotherapists influence and control others outside therapy. They may imbue therapists with greater power and authority than reality confers. Some adolescents may envision their therapist as a savior ready to provide rescue from antagonistic peers or oppressive administrators. Clarification is important:

Before starting, I want to make sure you understand my role. In therapy you and I work together to understand some of the things that might be bugging you and come up with solutions or ideas to try. But, even though I like to think I know everything and can solve any problem, there are limits to my power. For example, let’s say you’re having a conflict with peers. I would work with you to resolve these conflicts, but I’m not the police, and I can’t get them sent to jail or shipped to military school. I can’t get anyone fired, and I can’t help you break any laws. Does that make sense? Do you have any questions for me?

A clear explanation of the therapist’s role and an explanation about counseling process can allay uncertainties and fears about therapy. Inviting questions and allowing time for discussion helps empower adolescent clients, build rapport, and lower resistance.