Tag Archives: teenagers

Therapy with Adolescents

Information on Suicide Interventions for Counselors

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

Safety Planning

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

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

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

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

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

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

Identifying Alternatives to Suicide

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

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

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

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

Separating the Psychic Pain From the Self

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

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

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

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Personal Reflections, Therapy with Adolescents

ACA Conference in Cincinnati: Day One

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Yesterday was Day One of my American Counseling Association conference experience and it has led me to notice that whenever I dish up my plate, it always seems there’s a little food that falls off the edges. My grandmother used to say my eyes were bigger than my stomach, but that’s silly because I’ve looked at my stomach; if my eyes really were bigger, I’d look like a brother from another planet. Obviously, this is a metaphor.

The point is that I always try to fit too much material into my presentations. Yesterday I presented a 6 hour “Learning Institute” titled, “Counseling Challenging Teenagers.” It was a very nice experience with about 20 participants who care enough about working with teenagers to show up in Cincinnati 2 days before the conference actually starts for a spendy workshop. I was impressed with the participants and the questions and the dedication to learning and serving teenagers. Very cool.

However, not surprisingly, because as Robert Frost would undoubtedly contend, my reach consistently exceeds my grasp, I didn’t quite fit every part of the workshop content into the workshop . . . which brings me to the purpose of this post . . . which is to describe my next two postings . . . which will be on alternative to suicide and neodissociation as a suicide intervention . . . which were the two parts of the workshop that exceeded my grasp.

Highlights of Day One: The man who drove 18 hours from Maryland to attend (and managed to mostly stay awake); the woman who helped with the workshop as a volunteer and then was super-giddy about getting me to take a photo of her with Bob Wubbolding (and then, I think to humor me, acted excited to include me in an additional photo with the two of them); finding a Starbucks, Panera Bread, and Chipotle within blocks of the Convention Center.

More soon.

 

Parenting, Therapy with Adolescents

Give Information and then Back-Off: A Choice Theory Parenting Assignment

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Parent Homework Assignment 8-1 — From How to Listen so Parents will Talk . . . http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=sr_1_8?s=books&ie=UTF8&qid=1341892854&sr=1-8&keywords=how+to+listen+so+parents+will+talk+and+talk+so+parents+will+listen

Choice Theory Communication Skills Training: How to Provide Information and Then Back Off, Instead of Trying Too Hard to Control Your Child’s Decision Making

As a loving parent, if you’re concerned about your children’s behaviors, you’ll probably have a strong and nearly irresistible impulse to tell them how to live their lives. After all, you’re the adult and they should listen to your excellent advice. You may feel the urge to say:

  • You need to clean your room now because being disorganized and undisciplined is a bad habit that will make your life miserable.
  • Alcohol and drugs are illegal and so if you go out and behave illegally, I’ll call the police and have you ticketed.
  • You need to start caring about your grades at school and that means scheduling time for homework and studying for tests.
  • Swearing is unacceptable in this house and if you do it again, I’ll wash your mouth out with soap.

Unfortunately, as you may recall from your own childhood, when parents are bossy and insistent about how things should be, children often become more stubborn and resistant. Then parents begin to nag and lecture and the pattern of advice-giving and advice-rejection deepens. This assignment is designed to help you communicate important information to your children without starting an all-out power struggle or negative nagging pattern. The following suggestions are appropriate only if the situation isn’t dangerous and you don’t need to jump in and directly and forcefully protect your children:

1. Ask permission. If you have a strong opinion that you’d like your child to hear, try asking permission to share it. Say something like, “Can I share my opinion on this with you?” Then, either your child will say “yes” and you can share your opinion or she’ll say “no” and then you’ll need to accept her boundary (in response to a “no,” you might say, “Okay. Thanks for being honest with me. Let me know if you change your mind” and then walk away).

2. Express your intention not to express your opinion. You could try telling your child, “I have an opinion on this, but I trust that you can work it out, or that you’ll ask me for help if you need it. So I’m going to try to keep my mouth shut for now.” This gives your child the message that you’re trying to respect his ability to work out his own problems. You can also add humor into this or other power-sharing techniques by adding: “You should really appreciate this, because you know how hard it is for me to keep my mouth shut and not give you advice.”

3. Provide your information or opinion and then back off.  If you can’t resist giving your opinion, just do it and then back off and let your child consider your input. The key to this strategy is patience. Undoubtedly, you’ll provide excellent advice and then your child will look like she’s not considering your advice and so you’ll have the urge to repeat your advice over and over until you see action. Instead of falling into this pattern, try saying, “Look. I’ve got an opinion, which you probably already know. But instead of staying quiet, I’m just going to say it and then let you make your own decision on how to handle your situation. It’s your life. You have to make your own decisions. But I love you and can’t stop myself from telling you what I think, so here it is.”

As you probably already know, if you express your opinion you may get a strong emotional response (e.g., “I’m fifteen years old and I can make my own decisions!”). Although this seems weird, if you give lots of advice, your children may see your ideas and opinions as evidence that you don’t believe they’re competent to make their own decisions. This is why you should always express your advice with love and concern; avoid sounding as if your main goal is to control your child’s behavior.

Finally, if the situation is dangerous or potentially so, skip the less direct parenting recommendations listed above and instead think strategically about how to deliver direct advice that will be heeded. You’ll probably need to use a more direct approach than is described here, and you may need to consult with a professional.

More assignments like this and more are in the book, How to Listen so Parents will Talk — http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=sr_1_8?s=books&ie=UTF8&qid=1341892854&sr=1-8&keywords=how+to+listen+so+parents+will+talk+and+talk+so+parents+will+listen

Therapy with Adolescents

Getting Your Buttons Pushed by Teenage Clients

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The following material is adapted from Tough Kids, Cool Counseling.

Although we generally suggest not taking your client’s degrading comments personally, in the real world, we all get our buttons pushed sometimes. A graphic example of a therapist over-reacting to provocative client behavior was captured in the feature film, Good Will Hunting (Van Sant, 1997). 

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

During his initial session with McGuire, Will is his provocative and nasty self. He begins insulting McGuire’s deceased wife which “activates” McGuire’s emotional buttons. The result: McGuire grabs Will around the neck and slams him up against the wall. Of course, McGuire also decides to take on Will as a client and eventually (and rather magically) he successfully helps Will move forward in his life.

We’d like to emphasize two key points related to this excellent example of resistance and countertransference from Good Will Hunting. First, be aware of your emotional buttons. If you’re getting your buttons pushed, seek support and counseling for yourself. Second, no matter how provocative your young clients may act, avoid using Robin Williams’s “Choking the client” technique.  It may play well in Hollywood, but physical contact with resistant, aggressive, and/or angry clients is highly ill-advised. If you think rationally about the “Will Hunting” character and the fact that he had a history of physical trauma, touching him in an aggressive way would be ESPECIALLY contraindicated.

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

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Therapy with Adolescents

Flaws in the Satanic Golden Rule

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summer-13-long-shadow

Nearly always I learn tons of good stuff from my adolescent clients. A few years ago I learned what “Macking” meant. When I asked my 16-year-old Latino client if it meant having sex (I gently employed a slang word while posing my question), his head shot up and he made eye contact with me for the first time ever and quickly corrected me with a look of shock and disgust. “Macking means . . . like flirting,” he said. And as he continued shaking his head, he said, “Geeze. You’re crazy man.”

The next half hour of counseling was our best half hour ever.

I’m not advocating using the F-word or being an obtuse adult . . . just pointing out how much there is to learn from teenagers.

More recently I learned about the Satanic Golden Rule. A 17-year-old girl told me that it goes like this: “Do unto others as they did unto you.”

Now that’s pretty darn interesting.

Ever since learning about the Satanic Golden Rule I’ve been able to use it productively when counseling teenagers. The Satanic Golden Rule is all about the immensely tempting revenge impulse we all sometimes feel and experience. It’s easy (and often gratifying) to give in to the powerful temptation to strike back at others whom you think have offended you. Whether it’s a gloomy and nasty grocery cashier or someone who’s consistently arrogant and self-righteous, it’s harder to take the high road and to treat others in ways we would like to be treated than it is to stoop to their level to give them a taste of their own medicine.

There are many flaws with the Satanic Golden Rule . . . but my favorite and the most useful for making a good point in counseling is the fact that, by definition, if you practice the Satanic Golden Rule, you’re giving your personal control over to other people. It’s like letting someone else steer your emotional ship. And to most my teenage clients this is a very aversive idea.

After talking about the Satanic Golden Rule many teenage clients are more interested in talking about how they can become leaders. . . leaders who are in control of their own emotions and who proactively treat others with respect.

An excellent side effect of all this is that it also inspires me to try harder to be proactively respectful, which helps me be and become a better captain of my own emotional ship.

Parenting, Therapy with Adolescents

Serious Advice for Parents of Teens

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When Parenting Teenagers — Age Matters

Most parents easily recognize that when it comes to parenting, age matters a great deal.  If you’re not convinced, try giving your teen a nice, cuddly hug, preferably in public.  Not surprisingly, what’s fun and rewarding for one age group, is stupid, incomprehensible, or embarrassing for another.

Teens can be especially challenging for parents. Forgive the blunt language, but the truth is:  Teens often think adults in general, and their parents in particular, don’t know squat.  When I recently shared this well-known fact with a teenager, she gently corrected me by saying, “I think what you mean to say is that adults only know squat.”  I just rolled my eyes and said, “Whatever.”

In contrast to some of my teenage friends, I happen to believe that adults usually do have their squat together.  Therefore, I’ve written a short guide (with attitude) for anyone who has the daunting task of communicating with teenagers.

Principle 1: Always remember, on average, adults are usually smarter and wiser than teenagers.  This fact comes with a certain responsibility.  It means we should strive to really act like we’re smarter and wiser than teenagers.  This means, unfortunately, we have to act mature.  Sometimes we have to go the extra mile when trying to understand today’s youth.  It also means quickly forgiving them when their brains seem to malfunction.

Think about what it means to be more mature – and maybe even wiser – than your teenager.  Think of how to demonstrate your adult maturity in a way that your teen will respect.  Be concrete and specific.  For example, don’t think: “I’ll show my wisdom and maturity by trying to be more patient when he talks on and on about skateboarding.”  Instead, think something like: “I’ll make a point of asking him about his skateboarding at least twice a week. Then, if he’s up for talking, I’ll pay attention to him for at least 5 minutes before I change the subject or get distracted with something else.”

Principle 2: Many teenagers have a special invisible antenna that sticks out from the top of their head. Don’t bother looking for this antenna because it’s invisible.  It’s a “Respect Antenna.”  It functions to instantly ascertain whether a given adult likes or respects a given teen.  Consequently, although teens may act like they’re not paying any attention to you, they’ll still be able to psychically determine whether or not you like and respect them.  And if their invisible antennae signals that you don’t like or respect them, they’ll treat you miserably. Oh yeah. One more thing about this: Like everyone else, the teenager invisible respect antenna regularly malfunctions.

Principle 3: Many teens have dysfunctional eye rolls that appear completely beyond their voluntary control.  For some unknown reason, these eye rolls are triggered when adult authority figures make serious comments.  If you notice teens having this eye roll problem try your best to treat them with the sympathy they deserve.  This means you should smile while looking deeply into their eyes with every ounce of kindness left in your heart. You may think your teen is being disrespectful, but really she or he really needs your sympathy for this problem.

Principle 4: Teenagers are insecure.  Often, they cover their insecurity with a thin veneer of self-confidence and bravado.  This veneer has the effect of making adults assume that young people are confident or overconfident. Such an assumption can cause adults to back off and not offer help, when sometimes, help is exactly what your teen needs.

Principle 5: Young people are very good at tuning out adults while following the sometimes incredibly bad advice of their peers.  The best weapon we have against this sad trend is to sit and listen to young people as they talk about their lives, while, at the same time, resisting the impulse to give them our sage advice.  After listening for a considerable length of time, it can be effective to dress up one of your good ideas as one of their bad ideas and pretend that they came up with it.  If this subtle technique for influencing young people gathers no moss, then you may be forced back into the Dr. Science approach.  The Dr. Science approach essentially involves informing the youth that you know more than they do and therefore they MUST abide by your wishes.  This approach is usually effective only if you have way more money and way more valuable property than the young person.

Principle 6: Scientific research has clearly shown that, down deep, young people really want positive relationships with adults. . . AND that they greatly profit from such relationships.  Try to ignore the fact that adults conceived and conducted this research.  Instead, just go right on doing your best to develop positive relationships with as many teenagers as possible and go right on assuming they want those relationships.

Principle 7: In the end, you’ll find that communicating with teenagers is a lot like baseball.  In professional baseball, if you get a base hit 3 out of 10 times you go to the plate, you have a great chance of getting voted onto the All Star team.  The same is true for communicating with teens.  If you’re a lifetime .300 hitter, your child will probably eventually vote for your induction into the parental Hall of Fame!

If you want additional information about how to communicate more effectively with teens, we recommend parent education classes. You might discover several things: (a) there are other parents out there, besides you, who are struggling and want a better relationship with their teens; (b) many parents (and maybe even the class leaders) will have great ideas about how to improve your teen communication skills; and (c) by meeting with parents and talking opening about our challenges, we’re conspiring to prove that we’re indeed wiser than our teenagers.

[This blog is adapted from an old newspaper article in the Missoulian and from “The Last Best Divorce Workbook” (written by John and Rita Sommers-Flanagan and published by Families First Missoula, 2005)]