Tag Archives: therapy

Parenting

The Practically Perfect Parenting Podcast — Episode 2

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Hello Parents, Fans of Parents, and Fans of Healthy Child Development:

I need a tiny bit of your time and help.

As you know, the Practically Perfect Parenting Podcast was launched on October 31. Yesterday, Episode 2 became live. The title: Practically Perfect Positive Discipline. Today, I’m flexing my marketing muscles (which, as it turns out, are disappointingly more like Gilligan’s than the Incredible Hulk)

Podcasts are a competitive media genre. One way we can try to improve our status from way out here in little Missoula, Montana is for people to listen, like, and rate.

Here’s how you can help:

If you use iTunes, here’s the link. https://itunes.apple.com/us/podcast/practically-perfect-parenting/id1170841304?mt=2#episodeGuid=2d80f23353e2c7f9d21af865f190d2c4

Please check it out and if you like it, like it, and then give it the rating you think it deserves. We’re trying to get enough ratings to climb up the iTunes rating list.

If you don’t use iTunes, you can get to our podcasts via this link: http://practicallyperfectparenting.libsyn.com/2016

And, either way, we’d love it if you’d like our Facebook page. To do that, go here: https://www.facebook.com/Practically-Perfect-Parenting-Podcast-210732536013377/?notif_t=page_fan&notif_id=1479160427608384

In addition to your social media ratings, we’re ALWAYS interested in your supportive or constructive feedback. We also take questions and suggestions for new show topics. You can provide any or all of that here on my blog or directly to me via email at john.sf@mso.umt.edu

Thanks!

Dr. John and Dr. Sara, The Practically Perfect Podcasters

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Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Tough Kids Cool Counseling

Using an Invitation for Collaboration in Counseling and Psychotherapy

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As I’m sure you know, I believe (rather strongly) that counselors and psychotherapists should work hard to collaborate with clients. Being an authoritarian therapist is passe.

Sometimes collaboration sounds easy in theory, but it can be difficult in practice. It’s especially difficult if clients come into your office not “believing in therapy” and not trusting you. In the following excerpt from the forthcoming 6th edition of Clinical Interviewing, you can see how a skilled therapist deals with some initial client hostility.

Case Example 3.1: An Early Invitation for Collaboration

Sophia, a 26-year-old mother of two was referred for counseling by her children’s pediatrician. When she sat down with her counselor, she stated:

I don’t believe in this counseling thing. I’m stressed, that’s true, but I’m a private person and I believe very strongly that I should take care of myself and not have anyone take care of my problems for me. Besides, you look like you might be 18 years old and I doubt that you’re married or have children. So I don’t see how this is supposed to help.

It’s easy to be shaken when clients like Sophia pour out their doubts about therapy and about you at the beginning of the first session. Our best advice: (a) be ready for it; (b) don’t take it personally, Sophia is speaking of her doubts, don’t let them become yours; (c) be ready to respond directly to the client’s core message; and (d) end your response with an invitation for collaboration. An invitation for collaboration is a clinician statement that explicitly offers your client an opportunity to work together. In some cases, an invitation for collaboration is a time-limited “let’s try this out” offer.

Here’s a sample counselor response to Sophia:

Counselor: I hear you loud and clear. You don’t believe in counseling, you’re a private person, and you’re concerned that I don’t have the experiences needed to understand or help you.

Sophia: That’s right. [Sometimes when the counselor explicitly reflects the client’s core message (i.e., “. . . you’re concerned I don’t have the experience needed to understand or help you”) the client will retreat from this concern and say something like, “Well, it’s not that big of a deal.” But that’s not what Sophia does.]

Counselor: Well then, I can see why you wouldn’t want to be here. And you’re right, I don’t have a lot of the life experiences you’ve had. . But I do have knowledge and experience working with people who are stressed and concerned about parenting and I’d very much like to have a chance to be of help to you. How about since you’re here, we try out working together today and then toward the end of our time together I’ll check back in with you and you can be the judge of whether this might be helpful or not?

Sophia: Okay. That sounds reasonable.

In this case the counselor responded directly and with empathy to Sophia and then offered an invitation for collaboration. As the session ends, Sophia may or may not accept the counselor’s invitation. But either way, the counselor’s skillful response provides an opportunity for a collaborative relationship to develop.

Round Bales

 

Therapy with Adolescents, Tough Kids Cool Counseling

Teaching Teens Better Strategies for Getting What they Want

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On Thursday of this week I’ll be at the Hilton Garden Inn in Missoula doing a day-long workshop on how to work effectively with challenging youth and challenging parents. Of course, the first point to make about this is that this entire concept is flawed; it’s flawed because it’s not fair to call youth and parents “challenging” when, in fact, for them, the whole idea of sitting down and talking with a counselor is challenging. It would be equally reasonable to hold a workshop for parents and youth titled, “Working with Challenging Counselors.”

One of the approaches featured during the workshop will be to engage teenagers in using better (healthier and more legal) strategies for getting what they want. Rita and I wrote about this approach in our book, Tough Kids, Cool Counseling. . . and so here’s an excerpt that describes the approach and provides a case example:

INTERPERSONAL CHANGE STRATEGIES

The following techniques focus more specifically on interpersonal behavior patterns.

Teaching “Strategic Skills” to Adolescents
Weiner (1992) described many delinquent or “psychopathic” adolescents as inherently understanding the importance of using strategies to obtain their desired goals (p. 338). Despite this general understanding, disruptive, behavior-disordered adolescents frequently utilize ineffective interpersonal strategies and thereby obtain outcomes opposite to what they desire. For example, increased freedom is commonly identified by adolescents as one of their primary therapy goals. However, attention-deficit and disruptive, behavior-disordered adolescents consistently engage in behaviors that eventually restrict their personal freedom (e.g., curfew violation, disrespect toward parents, illegal behavior). The “strategic skills” intervention is designed to help adolescents understand how their own behavior contributes to their inability to attain personal goals (e.g., perhaps by producing increased limits and restrictions).

The therapist must provide two relationship-based explanations to implement the strategic skills procedure. First, the therapist must directly inform them of a willingness and commitment to assist them in personal goal attainment. For example:

It sounds like you want more freedom in your life. I imagine it’s a drag being 15 and still having all the restrictions you have. I want you to know that I’m willing to work very hard to help you have more freedom. We just have to put our heads together and think of some ways you can get more freedom.

The purpose of this statement is to reduce resistance and distrust. Many, if not most, adolescents expect therapists to side with their parents, teachers, or authority figures. The process of valuing the adolescent’s pursuit of freedom can surprise the adolescent and thereby reduce resistance.

Second, therapists must set clear limits on the type or quality of behaviors they are willing to support and promote. This is because adolescents may try to manipulate therapists into supporting illegal or self-destructive behavior patterns (Weiner, 1992; Wells & Forehand, 1985).

I need to tell you something about what I am willing to help you accomplish. I’ll help you figure out behaviors that are legal and constructive and help you get more freedom. In other words, I won’t support illegal and self-destructive behaviors because in the end, they won’t get you what you want. And there may be times when you and I disagree on what is legal and constructive; we’ll need to talk about those disagreements when and if they arise.

If adolescents respond positively to their therapists’ offer of support and assistance, the door is open to providing feedback about how to engage in freedom-promoting behaviors. Therapists can then tell their clients: “Okay, let’s talk about strategies for how you can get more of what you want out of life.” Subsequent discussions might include the following problem areas that frequently contribute to adolescents’ restrictions: staying out of legal trouble, developing respect and trust in the adolescents’ relationships with parents and authority figures, and analyzing and modifying inaccurate social cognitions. Essentially, therapists have facilitated client motivation and cooperation and can move on to analyzing faulty cognitions, modeling and role-playing strategies, and other effective psycho-therapeutic interventions.

Case example. A 12-year-old boy entered the consulting room in conflict with his father over how many pages he was supposed to read for a specific homework assignment given to him by a teacher whom he “hated.” The boy was disagreeable and nasty in response to his father’s comments; direct discussion of issues while both father and son were present was initially ineffective. Therefore, the father was dismissed. After using distraction strategies and a mood-changing technique (See Chapter 3), the boy was able to focus in a more productive manner on the conflict he was having with his father. The boy indicated that his father was partially correct in his claims about the reading assignment, but that the boy’s “hate” for this particular teacher made him want to resist the assignment.
The individual discussion between the boy and his therapist focused on (a) how the boy’s dislike for the teacher produced a “bad mood,” which subsequently produced his resistance to the assign-ment, (b) how the boy’s bad mood and resistance to the assignment had produced disagreeable behavior toward his dad, and (c) how the boy’s bad mood, resistance to the assignment, and disagreeable behavior had produced a bad mood and disagreeable behavior within the father (who was now resisting the boy’s request that the assignment be modified). Consequently, after the boy’s mood was modified, the boy and therapist were able to brainstorm strategies for helping the father change his mood and become more receptive to the son’s request. With assistance, the boy chose to tell the father “You were right about the assignment . . . “ when his father returned to the room. This “improved” interpersonal strategy (which had been role-played prior to father’s return) had an extremely positive effect on the father. Additionally, the boy was able to introduce a compromise (“I’ll do the assignment if my dad will listen to me without disagreeing when I bitch about how unfair and stupid this teacher is”). In response to his son’s admission “Dad, you’re right,” the father stated (with jaw open): “I don’t know what happened in here when I was gone, but I’ve never seen Donnie change his attitude so quickly.” Donnie and his father successfully negotiated the suggested compromise, and before Donnie left, the therapist pointed out (by whispering to the boy) how quickly he had been able to get his father’s mood to change in a positive direction.

In this case scenario, the therapist helped to modify the son and father’s usual reciprocal negative interactions in a manner similar to one-person family therapy advocated by Szapocznik et al. (1990).

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

Non-Drug Options for Dealing with Depression

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Evidence supporting the efficacy of antidepressant medications continues to be weak. That doesn’t mean they never work; some individuals with depressive symptoms find them very helpful and that’s okay. But for many, antidepressant meds just don’t work very well . . . there are side effects and less than desirable antidepressant effects. This is why many people wonder: What are some of the best non-drug alternatives for treating symptoms of depression?

Here’s a short list that might be helpful.

1. Counseling or Psychotherapy: Going to a reputable and licensed mental-health professional who offers counseling or psychotherapy for depression can be very helpful. This may include individual, couple, or family therapy.

2. Vigorous aerobic exercise: Consider initiating and maintaining a regular cardiovascular or aerobic exercise schedule. This could involve a specific referral to a personal trainer and/or local fitness center (e.g., YMCA). In a recent small study of adolescents with clinical depression, 100% of the teens in the aerobic exercise group no longer met the diagnostic criteria for depression after receiving several months of exercise treatment.

3. Herbal remedies: Some individuals benefit from taking herbal supplements. In particular, there is evidence that omega-3 fatty acids (fish oil) and St. John’s Wort are effective in reducing depressive symptoms. It’s good to consult with a health-care provider if you’re pursuing this option.

4. Light therapy: Some people describe great benefits from light therapy. Specific information on light therapy boxes is available online and possibly through your physician.

5. Massage therapy: Research indicates some patients with depressive symptoms benefit from massage therapy. A referral to a licensed massage therapy professional is advised.

6. Bibliotherapy: Research indicates that some patients benefit from reading and working with self-help books or workbooks. The Feeling Good Handbook (Burns, 1999) and Mind over Mood (Greenberger and Padesky, 1995) are two self-help books used by many individuals.

7. Post-partum support: There is evidence suggesting that new mothers with depressive symptoms who are closely followed by a public-health nurse, midwife, or other professional experience fewer post-partum depressive symptoms. Additionally, new moms and all individuals suffering from depressive symptoms may benefit from any healthy and positive activities that increase social contact and social support.

8. Mild exercise and physical/social activities: Even if you’re not up to vigorous exercise, you should know that nearly any type of movement is an antidepressant. These activities could include, but not be limited to, yoga, walking, swimming, bowling, hiking, or whatever you can do! In the same exercise study mentioned above, 71% of the teenagers in the mild exercise group experienced a substantial reduction in their symptoms of depression.

9. Other meaningful activities: Never underestimate the healing power of meaningful activities. Activities could include (a) church or spiritual pursuits; (b) charity work; (c) animal caretaking (adopting a pet); and (d) many other activities that might be personally meaningful to you.

The preceding list is adapted from a tip-sheet in our book, “How to Listen so Parents will Talk and Talk so Parents will Listen.” See: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_9?s=books&ie=UTF8&qid=1413432346&sr=1-9
Or: http://lp.wileypub.com/SommersFlanagan/

John and his sister working on their positive emotions.

Peg and John Singing at Pat's Wedding

 

Clinical Interviewing, Multicultural, Personal Reflections

Cultural Adaptations in the DSM-5: Insert Foot in Mouth Here

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Sometimes it just seems easier to be snarky than balanced. This basic truth comes to mind because of a recent analysis I did of the Cultural Formulation Interview (CFI) from the DSM-5. As I read about the CFI and looked through its Introduction and 16 questions for “patients,” I kept thinking to myself things like,

“Seriously . . . could this really be the best cultural sensitivity that the American Psychiatric Association can manage when it comes to guidelines for interviewing minority cultures?”

And,

“Who wrote this and why didn’t they ask me for some help?” (insert smiley face here; please note that some of my colleagues at the University of Montana have noticed—and commented—on the fact that I tend to insert a smiley face icon right after texting or emailing my personal version of punchy, snarky, sarcasm).

Ha! is all I have to say to them (FYI: Ha! is my programmed default back up to my default smiley face snark signal).

Anyway . . . the point! It’s way easier for me to be critical of the American Psychiatric Association than balanced. In truth, the CFI is a reasonable effort. And, if you think about where the APA is coming from (and likely going to) then the CFI is a massive effort. I should be saying, “Cool! I’m so excited to see the CFI as part of the DSM-5.

All this is prologue for the excerpt I include below. This is an excerpt from a draft chapter I’m writing for the Handbook of Clinical Psychology . . . to be published at some point in the not too distant future. Here’s the excerpt; it focuses on cultural adaptations we can make when conducting initial clinical interviews with minority clients; forgive the roughness of the draft.

Cultural Adaptations

A clinical interview is a first impression, and first impressions are powerful influences on later relational interactions, which is why we need to make cultural adaptations when conducting clinical interviews. One of the best sources for cultural adaptations is the already-existing guidance from psychotherapy research on working multiculturally. These guidelines include: (a) using small talk and self-disclosure with some cultural groups, (b) when feasible, conducting initial interviews in the patient’s native language, (c) seeking professional consultations with professionals familiar with the patient’s culture; (d) avoiding the use of interpreters except in emergency situations; (e) providing services (e.g., childcare) that help increase patient retention, (f) oral administration of written materials to patients with limited literacy, (g) having awareness and sensitivity to client age and acculturation, (h) aligning assessment and treatment goals with client culturally-informed expectations and values, (i) regularly soliciting feedback regarding progress and client expectations and responding immediately to client feedback, and (j) explicitly incorporating cultural content and cultural values into the interview, especially with patients not acculturated to the dominant culture (see Griner & Smith, 2006; Hays, 2008; Smith, Rodriguez, & Bernal, 2011).

Cultural awareness, cross cultural sensitivity, and making cultural adaptations are especially important to assessment and diagnosis. This is partly because mental health professionals have a long history of inappropriately or inaccurately assigning psychiatric diagnoses to cultural minority groups (Paniagua, 2014). To address this challenge, in the latest edition of the Diagnostic and Statistical Manual (DSM-5; American Psychiatric Association, 2014), a Cultural Formulation Interview (CFI) protocol is included to aid the diagnostic interview process.

The CFI is a highly structured brief interview. It is not a method for assigning clinical diagnoses; instead, its purpose is to function as a supplementary interview that enhances the clinician’s understanding of potential cultural factors. It also may aid in the diagnostic decision-making process. The CFI includes an introduction and four sections (composed of 16 specific questions). The four sections include:

1. Cultural definition of the problem
2. Cultural perceptions of cause, context, and support
3. Cultural factors affecting self-coping and past help seeking
4. Cultural factors affecting current help seeking

Questions from each section are worded in ways to help clinicians gently explore cultural dimensions of their clients’ problems. Question 2 is a good representation: “Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?” (American Psychiatric Association, 2014).

Clinicians are encouraged to use the CFI in research and clinical settings. There is also a mechanism for users to provide the American Psychiatric Association with feedback on the CFI’s utility. It may be reproduced for research and clinical work without permission, which is a cool thing.

If you Google: “Cultural Formulation Interview” the first non-advertised hit should be a .pdf of the CFI.

If you Google: “Clinical Interviewing” the first several hits will take you to some form or another of our text on the topic.

Here’s a photo of me “working” inter-culturally with my brother-in-law (insert smiley face here):

Rebekah.Johnson.photo_0451

 

 

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

 

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, Counseling and Psychotherapy Theory and Practice

Strategies for Working Effectively with Challenging Clients

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Working with clients who are reluctant or resistant to counseling can be very challenging . . . unless you use skills to help minimize resistance and maximize cooperation. The following is adapted from Chapter 12: Challenging Clients and Demanding Situations of the forthcoming 5th edition of Clinical Interviewing. Remember, these skills have to come from a foundation of therapist genuineness.

Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback

Clients sometimes begin interviews with expressions of hostility, anger, or resentment. If this is handled well, these clients may eventually open up and cooperate. The key is to refrain from lecturing, scolding, or retaliating when clients express hostility. Speaking from the consultation-liaison psychiatry perspective, Knesper (2007) noted: “Chastising and blaming the difficult patient for misbehavior seems only to make matters worse” (p. 246).

Instead, empathy, emotional validation, and concession are more effective responses. We often coach graduate students on how to use concession when power struggles emerge, especially when they’re working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). For example, if a young client opens a session with, “I’m not talking and you can’t make me,” we recommend responding with complete concession of power and control: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s need for power and control and concedes an initial victory in what the client might be viewing as a struggle for power.

Empathy and Emotional Validation

Empathic, emotionally validating statements are also important. If clients express anger at meeting with you, a reflection of feeling and/or feeling validation response can let them know you hear their emotional message loud and clear. In some cases, as in the following example, therapists might go beyond empathy and emotional validation and actually join clients with a parallel emotional response:

  • “Of course you feel angry about being here.”
  • “I don’t blame you for feeling pissed about having to see me.”
  • “I hear you saying you don’t trust me, which is totally normal. After all, I’m a stranger, and you shouldn’t trust me until you get to know me.”
  • “It pretty much sucks to have a judge require you to meet with me.”
  • “I know we’re being forced to meet, but we’re not being forced to have a bad time together.”

Radical Acceptance

Radical acceptance is a dialectical behavior therapy principle and technique based on person-centered theory (Linehan, 1993). It involves consciously accepting and actively welcoming any and all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). For example, we’ve had experiences where clients begin their sessions with angry statements about the evils of psychology or counseling:

Opening Client Volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.

Radical Acceptance Return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate psychologists but they just sit here and pretend to cooperate. So I really appreciate you telling me exactly what you’re thinking.

Radical acceptance can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. Our favorite version of this is the “Love reframe” (J. Sommers-Flanagan & Barr, 2005).

Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. So let’s just get this over with.

Therapist: I hear you saying this is bullshit. You must really love your daughter . . . to come here even when you think it’s a worthless waste of your time.

Client: (Softening) Yeah. I do love my daughter.

The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone, which turns the interview toward a more pleasant focus.

Genuine Feedback

Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings . . . pausing . . . and then following with honest feedback and a solution-focused question.

“I hear you saying you hate the idea of talking with me, and I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent]. You know, you’re in legal trouble. I’d like to try to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour or we can talk about how you might dig yourself out of this legal hole you’re in. I can go either way. What do you think . . . if we had a good meeting today, what would we accomplish?”

Think about how you can incorporate, empathy, emotional validation, concession, radical acceptance, and genuine feedback into your clinical practice. For more on this, check out the 5th edition of Clinical Interviewing.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

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

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

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

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

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

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

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