Transforming Therapeutic Relationships: Integrating Evidence-Based Practice

1. Transforming Therapeutic Relationships into Evidence-Based PracticePractical Skills for Challenging Counseling Situations John Sommers-Flanagan, Ph.D. University of Montana John.sf@mso.umt.edu https://johnsommersflanagan.com

2. Introduction • John Sommers-Flanagan, Ph.D. • Professor of Counselor Education, University of Montana • Author of Clinical Interviewing (6th ed., Wiley, 2017), Tough Kids, Cool Counseling (2nd ed., ACA, 2007) and many other books and journal articles • For resources: https://johnsommersflanagan.com/

3. Accessing Materials • To access the powerpointsand an extended handout associated with this presentation, go to: https://johnsommersflanagan.com/ • Or email: John.sf@mso.umt.edu

4. Learner Objectives • Define and describe evidence-based practice • List and describe evidence-based relationship factors (EBRFs) • Apply EBRFs in normal and challenging counseling situations [Opening story] • Use handouts and resources to continue learning

5. What is Evidence-Based Practice? • APA (2005) defined evidence-based practice as the integration of: • the best available research [and theory] • with clinical expertise • in the context of patient characteristics, culture and preferences.

6. Can We Be Relational and Scientific? • Norcross (2001, 2011, 2018) and others have put relational factors (e.g., Rogerian core conditions) on par with “empirically-supported techniques or procedures” by referring to: Evidence-Based or Empirically-Supported Relationships • Norcross is talking about the robust empirical support for specific and measurable relationship factors

7. Evidence-Based Relationship Factors • Congruence [Authenticity] • Unconditional positive regard [Respect] • Empathic understanding [Emotional attunement] • Culture Humility and Sensitivity [Equity in worldview] • WA1: Emotional bond [Liking each other] • WA2: Goal consensus [Adler’s goal alignment] • WA3: Task collaboration [Toward goal attainment] • Rupture and repair [Fixing relationship tension] • Managing Countertransference [Self-awareness] • Progress monitoring [Asking for feedback]

8. Overarching Workshop Goal • How can we integrate relational factors with technical strategies to maximize our effectiveness as therapists in general and in challenging situations? • Caveat: We have limited time and won’t cover everything. See the supplementary handout for more info. Ready, Set, Go!

9. Methods for Displaying Congruence • Informed consent process • Acknowledge reality/share referral information • Honest feedback – “May I . . .” • Authentic purpose statements • Responding to questions • Self-disclosure [in moderation*]

10. The Authentic Purpose Statement • Rationale: Clients/students benefit from hearing why you’re in the room. Make it brief; tweak for each client. • Counselor Behavioral Examples • “My goals are your goals. . .” • “I’d love to. . .” from TJ video • “I want to help you with. . .”

11. Responding to Questions • What are some (hard) questions you’ve faced or imagine facing? • Did you use drugs when you were in college? • I can only afford $20/hour; can you accept that? • Do you think I’m attractive? • Do you think I should leave my boyfriend (or girlfriend or partner)? • Are you a parent? [Do you have children?]

12. Responding to Questions II • Some questions include a challenge (always respond) • Example: Do you have children of your own? • Answer directly – No I don’t • Use a reflection – I hear a concern about whether I can be of help • Validate – I don’t blame you; I’d feel the same way • Use psychoeducation – I think I can help • Invitation for collaboration – How about we work together and you be the judge about whether this helps

13. 2 – Unconditional Positive Regard (UPR) The counselor’s experiencing and expressing warmth and acceptance. • When clients/students feel accepted, they can safely explore insecurities and weaknesses.

14. Displaying UPR • Being on time • Non-directive listening • Asking clients what is important to them • Remembering client details • Asking permission • Second (and third+) session first question • Using interactive summaries

15. Asking Permission • Asking permission shows respect for your client. • When using any technique, (a) ask permission to describe the technique (“Is it okay if we take a few minutes for me to describe this thing called progressive muscle relaxation?”); (b) describe the technique; and then (c) check in on your client’s reaction to the technique. • Ask permission to self-disclose or give feedback (“Is it okay with you to share something I’ve noticed?”).

16. Second Session First Question What do you remember from our first (previous) session . . .that felt important to you?

17. 3 – Displaying Empathy • Paraphrasing/reflecting • Reflection of feeling and feeling validation • Walking within (start where the client is, not where you want the client to be) • Rogers often used empathic clarification “Do I have that right?” • Starting from the empathic bottom

18. The Empathic Bottom • Working with clients who are depressed, suicidal, and expressing hopelessness (e.g., “Nothing helps!”) • Start with a basic feeling reflection (“It’s like I. . .”) • Ask what works worst • Then move up from the bottom • Same thing when exploring social connection (i.e., begin with who is the most toxic and move upward) • See: Suicide assessment and intervention with suicidal clients [Video]. 7.5 hour training video for mental health professionals. Mill Valley, CA: Psychotherapy.net.

19. 4 – Culture and Cultural Humility • Counselors are responsible for understanding when treatments require adaptation for diverse clients/students  • Cultural humility is an evidence-based orientation with three parts • An other-orientation instead of a self-orientation • Respect for others and their values/ways of being • An attitude that includes a lack of superiority

20. Cultural Humility • Broaching cultural differences when appropriate – not as a lock-step procedure • Acknowledging gaps in knowledge and asking about cultural values/orientation • Ex: “As we talk about goals, I’m aware that some Native people prefer goals linked to family, tribe, or community. What sorts of goals work best for you?”

21. 5 – The Working Alliance (3 parts) WA1: The Emotional Bond • Mutual liking between counselor and client/student Methods: • Being a secure base (counterconditioning) • Being “happy” to see the student/client • Comfort, competence, and dependability • Reframing alliance: “Punched my last counselor”

22. The Working Alliance WA2: Goal Consensus • Consensus and commitment to goals and means of reaching them. Methods • CBT/SFBT: Problem/goal lists • Wishes and goals [https://www.youtube.com/watch?v=rHHrMC8t6vY] and miracle question • MI: What you like; what you like less

23. The Working Alliance WA3: Task Collaboration • Counselors engaging students/clients in process/activities that both parties believe are relevant and helpful. Methods: • Tasks should connect with mutual goals (Rationale!) • Process: Ask permission; describe task; ask for reactions; set a low (experimental) bar; debriefing • Could be PMR, problem-solving, etc.

24. Rupture and Repair • Strains, impasses, resistance, and weakening of the therapeutic relationship. • Sooner or later, we all “fail” to get it right. • What are signs/types of rupture? • Withdrawal • Confrontation • Repair can be deeply therapeutic.

25. Repair Strategies • Repeat the therapeutic rationale • Change tasks or goals [Process?] • Clarify misunderstandings • Exploring relational themes associated with the rupture [culture*] • Repair doesn’t happen instantly

26. 9 – Countertransference Integrative Definition Therapist reactions based on unresolved conflicts, conscious or unconscious, and triggered before, during, or after counseling sessions.

27. Managing Countertransference • Be aware of the possibility • Seeks supervision • Get counseling • Own it in session • What are your CT stories? How do you manage your “issues” in therapy?

28. Countertransference • Tough Kids, Cool Counseling • What’s wrong with that title? • What’s a better title? • When Clients Say, “I don’t know.” • Take a guess • What if you did know? • When Clients Say, “I’m fine!” • Ask about who isn’t fine • Ask to focus on all the good things

29. 10 – Progress Monitoring • Check in like Rogers: “Am it getting that right?” • Use the Session Rating Scale • Check in for verbal feedback • Don’t be a love slob • What is the MOST important outcome of progress monitoring or client feedback? • You demonstrate INTEREST – UPR

30. Reflections and Discussion • What are your thoughts and reactions to the concept of EBRFs? • What would you like to remember from this presentation? • What would you like to apply in your counseling practice?

31. Resources • Sommers-Flanagan, J. (2018). Conversations about suicide: Strategies for detecting and assessing suicide risk. Journal of Health Service Psychology, 44, 33-45. • Sommers-Flanagan, J., & Shaw, S. L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48, 98-106. • Sommers-Flanagan, J. (2015). Evidence-based relationship practice: Enhancing counselor competence. Journal of Mental Health Counseling, 37, 95-108. • Sommers-Flanagan, J. (2018). Suicide assessment and intervention with suicidal clients [Video]. 7.5 hour training video for mental health professionals. Mill Valley, CA: Psychotherapy.net. • Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (3rd ed.). Hoboken, NJ: Wiley. • Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical Interviewing (6th ed.). Hoboken, NJ: Wiley. • Sommers-Flanagan, J. (2016). Assessment strategies. In M. Englar-Carlson (Ed.). The skills of counseling [Video]. Alexandria, VA: Alexander Street Press. • Go to https://johnsommersflanagan.com/ for tons of free stuff.

32. Resources • Go to https://johnsommersflanagan.com/ for free stuff on suicide, parenting tip sheets, mental status examinations, psychotherapy theories, the miracle question, and much more. • Plus many books: https://www.amazon.com/John-Sommers-Flanagan/e/B0030LK6NM/ref=dp_byline_cont_book_1 • Video training on suicide assessment and intervention is here: http://www.psychotherapy.net/video/suicidal-clients-series

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34. Questions? Dr. John Sommers-Flanagan Special Offer: 3 FREE months of website services Email: webinar@therapysites.com Call: 866.288.2771 Website: https://johnsommersflanagan.com Email: John.sf@mso.umt.edu