The Vocabulary of Reading

No one can ever prepare a parent for the confusion that comes when their child appears to learn in a different way from other children. And sometimes, we forget that parents of our students may also be struggling to understand how to help their child. Read more and download a helpful worksheet for parents: The Vocabulary of Reading.

Unlike many skills such as motor development (sitting, crawling, walking) that we are primed to learn via genetic code, reading is a skill we are not born with. Reading is a complex skill that entails understanding symbol-sound relationships, segmenting sounds, using visual-spatial skills to decode,  and attaching meaning to symbols, sounds and words. Last but not least, we have to comprehend the words as they are strung together.

Consider all that can get in the way as we need to see, hear, write, comprehend and speak in order to “learn to read.”

A lot of parents that have children struggling to read wonder, “why is this so hard for my child?”

No one can ever prepare a parent for the confusion that comes when their child appears to learn in a different way from other children. And sometimes, we forget that parents of our students may also be struggling to understand how to help their child.

One way to help engage parents in their child’s educational journey is to make sure they understand the everyday lingo we use in our offices. Words such as phonemes, graphemes, and phonics may be a part of our daily vocabulary, but for many parents these words are foreign.

To help parents understand the components of reading, here’s a worksheet you can provide them. It defines common words in speech language pathology and can help them feel more at ease when talking about their child’s progress.


Download the worksheet: The Vocabulary of Reading


This blog was contributed by PESI speaker Lynne Kenney, PsyD.

Lynne Kenney, PsyD, is a mom, pediatric psychologist, international educator and co-author with Wendy Young of BLOOM: 50 Things to Say, Think and Do with Anxious, Angry and Over-the-Top Kids. Lynne integrates neuroscience, nutrition, exercise and music research to enhance brain function and learning in children. For more “Think it Out” “Walk it Out” and “Play it Out” ideas visit www.lynnekenney.com.


Dyslexia, Dyscalculia and Dysgraphia: An Integrated Approach

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Online Course: Dyslexia, Dyscalculia, and Dysgraphia


3 Specific Rules for Managing ADHD

The CDC reports that 6.4 million children in the United States have been diagnosed with ADHD. As the prevalence of the diagnosis continues to rise, it’s important to have tools and strategies at the ready for managing ADHD in school.

Here are three classroom rules that are easy to implement and follow…

The following is based on the new release: Managing ADHD in School by PESI author Dr. Russell Barkley.


The CDC reports that 6.4 million children in the United States have been diagnosed with ADHD. As the prevalence of the diagnosis continues to rise, it’s important to have tools and strategies at the ready for managing ADHD in school.

Here are three classroom rules that are easy to implement and follow:

1. Rules and instructions provided to children with ADHD must be clear, brief, and often delivered through more visible and external modes of presentation than is required for the management of children without ADHD.

Stating directions clearly, having the child repeat them out loud, having the child utter them softly to themselves while following through on the instruction, and displaying sets of rules or rule-prompts (e.g., stop signs, big eyes, big ears for “stop, look and listen” reminders) prominently throughout the classroom are essential to proper management of ADHD children. Relying on the child’s recollection of the rules as well as upon purely verbal reminders is often ineffective.

2. Represent time and time period externally (physically).

Children with ADHD are less capable of using their sense of time to manage their current behavior and get work done in time, over time, and on time. When short time intervals of an hour or less are required to do work, then represent that time period using a clock, kitchen timer, counting device or other external means to show the child how much time they have and how quickly it is passing. A spring-loaded kitchen cooking-time placed on the child’s desk can serve this purpose. For longer time periods, break the work down into shorter periods with smaller work quotas, and allow the child to take frequent breaks between these shorter work periods.

3. Anticipation is the key with children with ADHD.

This means that teachers must be more mindful of planning ahead in managing children with this disorder, particularly during phases of transition across activities or classes, to ensure that the children are cognizant of the shift in rules (and consequences) that is about to occur. It is useful for teachers to take a moment to prompt a child to recall the rules of conduct in the upcoming situation, repeat them orally, and recall what the rewards and punishments will be in the impending situation before entering that activity or situation.

Think aloud, think ahead is the important message to educators here. By themselves, such cognitive self-instructions are unlikely to be of lasting benefit, but when combined with contingency management procedures they can be of considerable aid to the classroom management of ADHD children.


Russell A. Barkley, Ph.D., is a Clinical Professor of Psychiatry at the Medical University of South Carolina. He served as the Director of Psychology at the University of Massachusetts Medical School for more than 15 years (1985-2000) and established the research clinics for both child and adult Attention Deficit Hyperactivity Disorders.


Get the tools and strategies you need to help your youngest clients enjoy childhood to the fullest. Featuring Drs. Russell Barkley, Temple Grandin, Tina Payne Bryson and more. Limited capacity! Register now.

2016 Child Development Online Conference

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What Does it Mean to be a Culturally Competent Counselor?

As clinicians, we are often called upon to support and treat people during their incarceration, release, and parole. We also support their family members during this time. Understanding how social injustice, like racism, poverty and mental illness, contributes to incarceration is essential to effective clinical care.

In the United States, the legacy of slavery is a cultural wound that remains unresolved and unhealed, and it has resulted in, among other symptoms, the mass incarceration of African American men and women.

More people are imprisoned in the United States than in any other country in the world; and people of color constitute a disproportionate part (60%) of the incarcerated.

The Sentencing Project has further broken down the chances of being imprisoned by race, and the numbers are eye opening:

  • African-American men have a 1:3 chance of being imprisoned
  • Spanish-speaking men have a 1:6 chance of being imprisoned
  • European descendants have a 1:17 chance of being imprisoned

It might also surprise you to know that American Indians are jailed at a 38% higher than the national rate according to the U.S. Commission on Civil Rights.

These disproportionate incarcerations are linked to differential treatment by the criminal justice system, lack of access to adequate counsel, and racial profiling.

As clinicians, we are often called upon to support and treat people during their incarceration, release, and parole. We also support their family members during this time. Understanding how social injustice, like racism, poverty and mental illness, contributes to incarceration is essential to effective clinical care. This awareness allows us to speak  up when we see the mental health system perpetuate myths that oppress people; for example, treating substance abuse or incarceration due to drug use as an “illness” rather than  symptoms of a far greater problem such as trauma, intergenerational trauma and social injustice.

There are many factors that can contribute to our failure to engage social injustice such as: lack of awareness, “white fragility” and denial, compassion fatigue and a sense of helplessness. We become inured to the ongoing effects of racism and oppression in peoples lives. This also occurs if we do not allow ourselves to experience the daily direct effects.

But as clinicians, we are confronted with the effects of oppression in the lives of our clients every day.  Personal and social oppression affect physical and mental well-being.

What do we need to know about that to improve our work with clients? How do we deepen our understanding of our own internalized oppression?

There are so many levels at which this is important, and yet one that directly affects our clients is the concept of allostatic load. Allostatic load is defined as the “wear and tear” effect of chronic stress from daily life on the body and mind. Racism, bigotry and poverty all contribute to allostatic load, and this load accumulates during a lifetime leading to mental and chronic physical illness; especially illness that is autonomically mediated like cardiovascular disease and diabetes. It is believed that to be due to the effects of racism in the U.S., African-Americans have higher early mortality compared to non-Hispanic whites.

In today’s culture of social injustice, we are no longer just clinicians: we are social justice advocates. We take on this role every time we are asked to treat someone who is incarcerated, addicted, or has multiple physical illness co-occurring with PTSD. And it doesn’t stop there.

Our work goes beyond the daily routine of our office–our mandate is to advocate and act. To be successful clinicians, our work in multicultural competency must incorporate anti oppression. To do this, we incorporate understanding about the structural racism at work in our practices, our agencies, jails and the society at large.


Further learning about “Race” in America

Read: Multicultural Counseling Workbook: Exercises, Worksheets & Games to Build Rapport with Diverse Clients by Leslie Korn

Watch: Advance Your Cultural Competency in the Clinical Setting: DSM-5® Guidelines, Ethical Standards and Multicultural Awareness, a CE seminar with Leslie Korn.

Listen: When Ancestry Search Led To Escaped Slave: ‘All I Could Do Was Weep’, an interview with author Regina Mason.

View: The Dhamma Brothers story of the introduction of Vipassana meditation into a maximum-security prison in Alabama.


leslie korn 2015

Leslie Korn, Ph.D., MPH, LMHC, has over 35 years of experience in cross cultural counseling, research, and traditional healing practices. For over 10 years, Dr. Korn was the president of a multicultural consulting firm to design and implement multilingual and multi-ethnic mental health and wellness programs to reduce chemical dependency in urban Boston and rural Massachusetts. She lived and worked in the jungle of Mexico for over 20 years where she directed a public health clinic working alongside traditional healers. She has contributed to the design of cultural revitalization programs for mental health in tribal communities in the Pacific Northwest and Canada and has provided over 40,000 hours of private practice and agency-based clinical treatment to diverse individuals, families and communities.

Dr. Korn has a dual doctorate in Behavioral Medicine and Traditional (indigenous) Medicine and a Masters of Public Health from Harvard School of Public Health. Dr. Korn also earned a Masters in cross-cultural health psychology from Lesley University. She was a clinical fellow in psychology and religion at Harvard Medical School. An approved clinical supervisor, licensed mental health counselor, Fulbright scholar and NIH-funded scientist, Dr. Korn is the author of Nutrition Essentials for Mental Health: A Complete Guide to the Food-Mood Connection (Norton, 2016),  Rhythms of Recovery: Trauma, Nature and the Body (Routledge, 2012) and Preventing and Treating Diabetes Naturally, The Native Way (Daykeeper Press, 2010). Dr. Korn is core faculty and fieldwork supervisor in mental health counseling at Capella University and maintains bilingual clinical consulting practice in Puerto Vallarta, Mexico.

 

4 Strategies to Jumpstart Progress When Therapy Stalls

What do you do when a client stops making progress in therapy and it seems like your sessions are going nowhere? There are many reasons why this can happen including fear of change, unresolved trauma or a lack of clarity between client and therapist on the goals for therapy. Here are 4 strategies that not only dissolve standstills, but can also trigger big breakthroughs for your clients.

Counselor Courtney Armstrong explains what can cause therapy to stall and offers 4 simple strategies for getting a client moving again when they have got stuck.

What do you do when a client stops making progress in therapy and it seems like your sessions are going nowhere? There are many reasons why this can happen including fear of change, unresolved trauma or a lack of clarity between client and therapist on the goals for therapy. In this article I will share 4 strategies that not only dissolve standstills, but can also trigger big breakthroughs for your clients.

Please note: all client names have been changed to maintain confidentiality.

Strategy #1: Respectfully Address the Impasse and Normalize Fears of Change

Although clients seek therapy to make changes in their lives, the act of making those changes can seem scary or daunting. For example, my client Susie initiated therapy because she kept getting into relationships with men who had addictions. When she contacted me she was in an extremely codependent relationship and said she wanted to gain the courage to get out of it and build her self-esteem.

Susie actively participated in our first few sessions and showed a great deal of insight. Around our 4th session, she felt her self-esteem had greatly improved. Yet, she still couldn’t bring herself to break off the dysfunctional relationship with her boyfriend, who had recently stolen money from her and wrecked her car while driving drunk.

In the next several sessions Susie seemed to just want to complain about the emotional and financial burden this relationship placed on her. She dodged my best efforts to explore her deeper fears with replies like:

“Oh, I am planning on ending this relationship and setting boundaries like we talked about. I just can’t do it right now because he is dealing with the DUI and all. I’ll wait and do it after we get all of that resolved.”

Then, she’d go back to complaining about her frustrations with him.

When I found myself feeling bored and exasperated in our sessions, I knew I had to be more direct. I said:

“Susie, I feel like our last few sessions have degraded into focusing on all the ways you are unhappy in this relationship. But, that’s not going to lead you out of this dilemma. We’ve got to look at the fear and guilt that’s holding you in this pattern if you want to get any relief from it. Can we focus on that for a minute?”

Susie nodded and replied:

“I know. I guess I’m scared that either he’ll die if I don’t help him or that I won’t find anyone else to love me if I leave this relationship.”

This led to a much richer session in which Susie revealed an attachment trauma with her father who was a recovering alcoholic. Prior to this, she’d never disclosed that her father had a drinking problem. At the end of the session, she thanked me for redirecting her and asked that I continue to keep her accountable if she lost focus in the session.

Strategy #2: Explore For Earlier Traumatic Experiences

Just as Susie revealed, internal conflicts about change are often rooted in a prior emotional trauma the client has experienced. The problem is that many clients won’t connect these prior experiences to their current problem. Susie discovered this connection when I asked her if her feelings of guilt and fear around setting limits with her boyfriend reminded her of any other relationships in her life. It took a few minutes, but her eyes widened as she recalled an incident from her childhood when her father came home inebriated and her mother asked him to leave. Susie said her father went into a tirade and told her mother:

“Fine I’ll leave. But no one will ever love you and Susie like I do.”

He got into a car accident that night and suffered a head injury that left him in a coma for several days.

Although he survived, Susie thought her father was going to die and continued to fear for his life any time he started drinking. He eventually stopped drinking and they have a pretty good relationship now, which is why she’d never consciously connected her relationship with her father to her current relationship problems.

Susie realized she’d inadvertently acquired the belief at a young age that that she and her mother should put up with her father’s drinking so “he wouldn’t die” and because “nobody would ever love them like he did.” Once we were able to reprocess this memory and these associated beliefs, she felt much less compelled to accommodate her boyfriend’s drinking and made headway in stopping her codependent patterns.

Strategy #3: Consider the Downside of Being Free of the Problem

Sometimes being free of a problem creates a host of other new problems. For example, when I asked one of my clients who struggled with recurrent depression and chronic fatigue what the downside would be to feeling content and having more energy, she realized that her family would make more demands of her if she wasn’t chronically tired and depressed. She said the only time she ever felt like it was okay to rest and take a break was when she was sick.

Similarly, another client who suffered horrific physical abuse as a child discovered that his pattern of depression and underachievement was his way of holding his father accountable. He commented:

“Damn. I hate to say it, but if I’m successful and happy, then my father will continue to think he did a great job as a parent. Being a screw-up is my passive-aggressive way of punishing him for how he treated us. I know that sounds crazy, but I think that’s why I always stop short of achieving success in anything I do. Whenever I achieved anything as a kid, like making the All-Star baseball team, he took credit for it. I don’t want to give him that satisfaction.”

Another example in this category could be a person in an unhappy marriage with children. As miserable as they may be in the relationship, the thought of leaving the relationship, moving house, managing all the financial stressors, and upsetting the children seems worse than staying with the “devil they know.”

In all of these cases, it takes much more time and preparation to determine a feasible long-term goal. Therapy sessions may be better suited to assisting the client in achieving small goals that make their living situation more tolerable until they are in a position to make a bigger life change.

Strategy #4: Clarify That You and Your Client Are In Agreement on Desired Goals

Therapists are generally well-intentioned and seek to help clients move toward what is in their best interest. But, if the client doesn’t agree with the therapist’s intentions for the sessions, therapy is likely to go nowhere. This discordance between the client’s agenda and the therapist’s is not always obvious or clearly stated. The client’s nonverbal cues will let you know if you’ve hit on an appealing goal that triggers his or her motivation.

For instance, I worked with Saundra who said she wanted me to assist her in better managing stress at work. She had lost her temper a couple of times on the job and had been given a written warning. I noticed that when we were exploring ways she could center herself and adjust how she was approaching work tasks, her motivation seemed superficial at best. I commented:

“Saundra, I can tell these goals aren’t really lighting you up, so I think there must be something else I’m missing. What is more important to you than your job? What would being less stressed at work enable you to do?”

Saundra began to cry and said:

“My kids! I want to be able to come home and enjoy being with my children. I hate coming home in a bad mood every night and I resent my company for making us work more and more hours.”

Aha! This was the real source of Saundra’s angry outbursts at work. She felt like her job was taking away time with her children. When we centered our therapy on creating more space and time for her kids while balancing demands at work, she progressed quickly.

Closing Thoughts

In sum, when therapy stalls, it is usually because there is an internal conflict about making a change or about realizing the goal itself. The first step is to acknowledge to the client that you are aware things aren’t moving forward for them and ask them what they think might be causing the problem. If you sense they feel apprehensive about making a change, reassure them this is normal and invite them to give voice to their fears.

Second, explore for any earlier experiences that may be contributing to the current pattern they want to change. Even when a person knows a certain belief, behavior, or relationship pattern is irrational; his subconscious, emotional brain will sustain patterns that seemed to work in the past until he has a new emotional experience that changes the pattern.

Third, invite the client to consider what the downside of achieving their goals might be. Again, clients may not be consciously aware of possible drawbacks until you give them a safe place to look at them.

Last, make sure that you and your client have the same goals and agendas for therapy. Clients often look to the therapist to set the goals for a session and may not feel comfortable voicing their hesitation about moving forward. Furthermore, they may not even understand why they lack the motivation to follow through and blame themselves for falling short of their goals. You can avoid this by reading the client’s body language, which will instantly let you know when you’ve hit on a goal that really motivates them. When you’re in the zone of a viable, appealing goal, the client will be more animated, her facial expressions will broaden, and she’ll be more enthusiastic in her participation. If you’re not seeing these signs, then ask your client:

“What else do I need to understand? What am I missing? What would be the best thing that could come out of these sessions?”

They’ll tell you. All you have to do is ask and give them a safe place to tell their truth.


Courtney Armstrong, LPC, MHSP, is a licensed professional counselor in Chattanooga, Tenn., and the author of “The Therapeutic ‘Aha!’: 10 Strategies for Getting Your Clients Unstuck.” She also offers training and free resources for therapists at her website: www.courtneyarmstrong.net.

Out of the Tunnel: A Series on escaping the path of depression—Part 2

What happens when you ask your depressed client to help you map out not only the contours and geography of their suffering but also their competence and better moments? You get a new strategy for treating depression: marbling.

Written by Bill O’Hanlon, MS, LMFT


In the first part of our series on marbling depression, we explored three techniques to reflect in the past tense, localize global thoughts and validate perceptions. Now we will explore another method of marbling depression: Inclusion.

Inclusion

A while ago, I heard a story about a study of people who’d jumped off the Golden Gate Bridge, intending suicide, but had been rescued or survived the attempt. The researchers were searching for something that might help them identify people at risk and prevent future suicides. They found one commonality among the survivors: on the way down from the bridge to the frigid waters below, almost all of them had some variation on the thought Maybe this wasn’t such a good idea. That indicates to me that very few people are 100 percent hopeless, even in the moments before their imminent death (or perhaps they’re even more ambivalent when things have gone so far).

The inclusion method tries to acknowledge and capture this complex experience using three techniques.

1. Permission

In addition to feeling depressed, many people who experience depression feel that they’ve done something wrong, or are feeling the wrong feelings, or are thinking the wrong thoughts, or are just basically “wrong” in some fundamental way. One way to help them with this sense of wrongness is to give them permission to feel, be, or think the way they do-and not to feel, be, or think the way they don’t.

This means that there are two kinds of permission that can be helpful with people who are depressed: “Permission To” and “Permission Not To.” These two types of permission are reflected in the following statements: “It’s okay to feel depressed” and “You don’t have to have hope right now.”

Now I want to be clear here that the permissions I suggest are mostly about experience, not actions. For example, I wouldn’t say to someone, “It’s okay to kill yourself,” but instead, “It’s not unusual for people feeling as bad as you do to think about killing themselves. It’s okay to think that. It doesn’t mean you’ll act on it.” So there’s no permission for self-harming actions or actions that might hurt someone else.

Here are some examples of suggested permissive responses.

Depressed person: “It’s all meaningless.”

Possible responses: “It’s okay not to have meaning right now.” “You don’t have to know what it all means right now. We’re just working on how to get you feeling better today and tomorrow.”

Depressed person: “I feel hollow.”

Possible responses: “It’s okay to feel hollow.” “Feeling hollow is pretty common for someone who’s depressed. You don’t have to feel any other way right now.”

2. Inclusion of Opposites

The next way to give permission is more complex and nuanced and may be especially helpful for people who are depressed. It involves giving permission to have two opposite feelings or to be two ways at once. For example, someone may feel like dying and also want to live. Or he may feel like killing himself but not want to hurt his family and friends by killing himself.

This technique, then, involves giving the depressed person permission to include, feel, or be those contradictory things simultaneously. One major way to communicate this is to connect the two contradictory aspects with the conjunction and. The word and signifies inclusion of both, whereas the conjunctions but and or imply one or the other.

“You felt as if you couldn’t get out of bed today, and you got up and came to see me.”

“You wanted to give up, and you wanted to keep going.”

“You feel as if there’s is no end to this, and you think you’ll come out of it.”

“You can’t find your sense of meaning, and you think you’re going through this depression for a reason.”

“You don’t want to die, and you don’t want to live like this.”

You might have to stumble around with this before you hit on the inclusive reflection that really moves the person, helps him feel both understood and validated at a deep level, and perhaps helps him shift in some way. This technique can be challenging because this isn’t a logical way to speak or think.

3. Oxymorons

In the English language, we have a natural way to use inclusion called the oxymoron. This is when two opposite concepts are put together in a two-word phrase, such as sweet sorrow or exquisite suffering. A more expanded way of using oxymorons is to spread them apart in a sentence or phrase; this is called the apposition of opposites.

“It’s important to remember to forget certain things and not to forget to remember other things.”

“It seems that you’ve spent so much time in darkness that your eyes have adjusted and can see things in the dark that others can’t.”

“You’re hoping against hope that this depression will lift.”

As you can see from the above examples, there can be a place for using oxymorons in therapy to emphasize that it’s okay and even beneficial to have conflicting perceptions and experience opposing ideas. One last application of the inclusion of the opposites technique is to include the negative with the positive by using tag questions. Tag questions are little questions added on to the end of a statement that seem to say the opposite.

Milton Erickson once told me, “If you can’t say the ‘no,’ the patient has to say it.” He regularly used these tag questions. Here are some examples:

“You don’t think you’ll get better, do you?”

“You’re not feeling better, are you?”

“You’re starting to feel better, aren’t you?”

If you think of the Asian symbol of the yin yang, you will get this technique. There is a yes in the no and a no in the yes, and they complete each other to make a whole. The point of this method is to help people become more integrated, including all their aspects, so they feel less fragmented or troubled by the disparate aspects of their experience, feelings, or personalities. Without this integration, clients often feel ashamed or torn in two directions, which can increase their emotional distress and deepen their depression.

Exceptions

Very rarely is someone always depressed, or always empty, or always without energy, or always suicidal. If you and the person you’re helping explore exceptions to the usual problem, feeling, or thought, you can usually find moments when it’s not occurring. A lot can be learned from these exceptions that may be helpful in finding relief from the depression, so here we’re just trying to do some marbling by acknowledging that there are exceptions to the rule of whatever the person’s complaining about or isn’t working for him. For example, he has no energy (except when he does). Or he can’t get out of bed (except when he does). He feels bleak (except when he doesn’t). He never laughs anymore (except when he does).

Here’s an example of a client-therapist interaction in which the client talks about his depression but indicates that there’s more to the story than just depression.

Client: “Sometimes I just feel so hopeless. I don’t know if I’ll ever come out of this hole I’m in. Maybe getting this new job will help. My old job just sucked.”

Therapist: “When you’re afraid you won’t come out of it, it seems hopeless, but when you think about this new job, you get some sense of hope.”

One specific way to discover and highlight exceptions is to listen for and acknowledge moments of non-depression. Perhaps the person got absorbed in a movie and “forgot himself” for a few hours. Perhaps he spent time with a friend or family member and felt better for a time. Perhaps there was a time in the recent past when, inexplicably, his depression was better for a day, a week, or longer.

Another way to find exceptions is to find out about what happens when the depression starts to lift that’s different from what happens during the depressive episode. Maybe the person starts to become more social, or listens to music more, or goes out of the house or eats different foods. Of course, one way to find out what happens when the depression starts to lift is to listen for reports of those times, but you can also elicit such reports by asking about them directly. Here’s an example of such a direct elicitation: “I’m curious. You’ve been through these times of depression before and have come out of them. What happens when you start to emerge from that darkness and begin feeling better?”

One last way to discover exceptions is to investigate why the depression isn’t worse or the person isn’t less functional. This is sort of a backward way of discovering exceptions. For example, you might ask your client, “How have you been able to go to work or visit with friends when some people with depression haven’t been able to do those things?” Or, “What’s stopped you from acting on those suicidal thoughts?” Or, “Why haven’t you given up on seeking help?” The answers to these and similar questions can contribute to the marbling.

Here’s an example of the kind of inquiry you might make: “I was a little surprised to hear that you finished that big project at work even though I know you’ve been feeling like hell. If I were talking to someone else who was depressed and had a similar kind of project in front of them, what would I tell them about how you were able to pull that off even though you felt so impaired?”

Depression as a Bad Trance

I learned hypnosis many years ago when I began to recognize some similarities between a hypnotic trance and what I began to think of as a “symptom trance” or “problem trance.” Both types of trances often involve a narrowing of the focus of attention, and the induction of both involves rhythmic repetition. In Sense and Nonsense in Psychology, Hans Eysenck tells a story about a young English surgeon, just about through with his training, who was drafted into the army during World War I and sent to fight on the fields of France. On the battlefield, he came across a French soldier severely wounded by a mortar shell, writhing in pain and doing further damage to himself. The soldier was in imminent danger of dying unless the Englishman could get him to stay still until he could get him back to the surgical tent for treatment.

In desperation, the Englishman remembered a demonstration of hypnosis he’d seen during his medical training and decided to try what he remembered of hypnotic induction. But he didn’t know much French, so the best he could do was repeat again and again to the writhing Frenchman the only French words he could conjure up: “Your eyes are closing. Your eyes are closing.”

To his amazement, the Frenchman stopped writhing and his breathing slowed. He appeared to be in a trance that lasted long enough to get him back to the medical tent, where the British surgeons did indeed save his life. After the operation, the medical student told the British surgeons the story of his hypnosis. They all began laughing and told the baffled student that what he had really said was “Your nostrils are closing. Your nostrils are closing.”

What the story illustrates is that it was the repetition, not necessarily the correct words, that had the hypnotic effect. In a more insidious way, a similar process happens in depression. The depressed person repeats the same thoughts, activities, feelings, and experiences again and again and begins to become entranced. Only the trance is not a healing trance, a therapeutic trance, but a “depression trance,” which induces more and more depression as it’s repeated. Marbling can be an invaluable tool in breaking the depression trance.


For the past 30+ years, Bill O’Hanlon, MS, LMFT, has given over 2,000 talks around the world and was awarded the Outstanding Mental Health Educator of the Year in 2001 by the New England Educational Institute. He is a Licensed Mental Health Professional, Certified Professional Counselor, and a Licensed Marriage and Family Therapist. An accomplished author, Bill is known for his storytelling, irreverent humor, clear and accessible style and his boundless enthusiasm for whatever he is doing.


This post is based on an article originally brought to life by our partner, Psychotherapy Networker.

The full article, “Out of the Tunnel: Escaping the Trance of Depression” written by Bill O’Hanlon, appeared in the Nov/Dec 2014 issue of Psychotherapy Networker magazine.

Lessons in Compassion, Faith, and Healing: The life of a nurse

When I sat down to talk to Shirley Davis, she reminded me a bit of Peter Pan; living a life of adventure, exploring new challenges, and caring for those when they feel lost. Even through the phone, her energy and love of life that had been described by her coworkers and patients was contagious.

The following captures only a glimmer of the compassion, love, and ambition of what it means to be a nurse going above and beyond the call of care.

Where do I begin to describe the extraordinary oncology nurses who have touched my life this year? I am going to tell you about one of these special healers who, on the very first day she was assigned to administer my chemo, touched my soul.

Of all the job duties and qualifications that an oncology nurse has, there is one that isn’t on any mandatory list. But it is written on the heart of these nurses and is the “rock” of their healing and nurturing talents. Tools of the trade include nursing skills and healing knowledge, medications, the latest in cancer treatment news, and in some cases, being able to read the doctor’s minds.

In the midst of all these skills and knowledge, there is a gift that these angels of healing have -a special cure gene that is deep seated in their heart. It is not seen on any x-rays or felt by the human hand, it is a “spirit” all its own. It is felt in the patients’ heart, mind and soul – a gift like NO other, given by these nurse angels.
–May “sissy” Graham Smith, patient of Shirley Davis, RN

These were just a few of the many words I read recommending Shirley Davis as a PESI dedicated nurse. I knew from the kind words of patients and colleagues that this nurse was special, but nothing could have prepared me for her love and compassion.

When I sat down to talk to Shirley Davis, she reminded me a bit of Peter Pan; living a life of adventure, exploring new challenges, and caring for those when they feel lost. Even through the phone, her energy and love of life that had been described by her coworkers and patients was contagious.

The following captures only a glimmer of the compassion, love, and ambition of what it means to be a nurse going above and beyond the call of care.


On Becoming a Nurse
Davis was drawn to nursing later in life.

“I have an associate’s degree in computer robotics. It’s never been any use. I didn’t discover nursing until I started working as an activities director for a nursing home. I fell in love with the residents there and working with them. One day it just clicked that nursing was my calling.”

Davis began working full time during the day and taking classes at night to get through her degree. In 2006, at the age of 42, she became a Registered Nurse.

“My sons were really excited for me when I graduated. I was, at one time, a single mother who worked two jobs to survive. There had been some tough times, but we got through things.”

Starting as an RN in Cardiac, Davis had a love of open heart surgery. She never imagined leaving the unit, but at the coaxing of a friend, she applied for a position in oncology.

“Working in oncology has been extremely humbling, especially about the gift of life. The age is so young with cancer. I love to just be with my patients; to cry with them, to laugh with them, or to pray with them.”

Faith and the Cancer Journey
When patients walk through the door at Wellmont Cancer Institute, there are many emotions: Fear of the unknown, sadness, anger, and confusion can all bubble to the surface. But shortly after they enter the doors, patients begin to feel the uplifting atmosphere created by the staff.

“Faith keeps this place going with all the heartache,” Jessica Bembry, RN, said. “You can feel Shirley’s love throughout this whole clinic. Everyone knows her here, and they know how strong her faith is. She shares her faith with our patients and is very inspiring to those around her.”

Prayer and faith define Davis as a caregiver. In a unit that copes with death every day, her faith helps guide her through the roller coaster of emotions that comes with cancer treatment.

Davis says, “My patients have taught me so much about faith. When I talk to them and ask them how they do it, all of them tell me it’s God.”

On Everlasting Love
“When patients come in and they’ve been husband and wife for so many years, you know they’re two peas in a pod. You see it in their eyes, and they know that they’re going to lose their love. That’s hard,” Davis explains.

Recently, Davis had the opportunity to care for a couple who were coming to the end of their cancer journey. A patient with pancreatic cancer was about to enter hospice care. He sat in Shirley’s chair and told her how he and his wife wanted to go to the beach. Davis knew she had to make it happen.

Using her personal funds, Davis arranged for the couple to spend a long weekend in Hilton Head. “He has since passed on, but I would do this every day if I could.”

On Being a Coach
Patient May “Sissy” Graham Smith knows first-hand that Davis’ works around the clock. She writes…

She (Davis) has also added coach to her job description with me as she has taken on advising me about nutrition, building up my strength, etc. She emails or messages me (Most times late at night after she gets home from work) asking what I’ve eaten, or telling me to try this or that. I had to take a two week break from chemo due to potassium problems and severe nausea. My off time was spent trying to gain weight and get stronger. I don’t need to tell you who called or wrote to check on me every day. With her coaching and my determined attitude, I went from 93 pounds to 101.4.

Davis notes that when you become a nurse, you take on a role that needs to bring spiritual, physical, nutritional, and holistic approaches together with modern medicine.

On Loving Your Job
Davis notes that she’s lucky because she loves coming to work. Even in a field where grief comes daily, she enters the center with high energy and hope every day.

“When you’re a nurse, you have to work as a team and be on the same pages as your fellow nurses. Being an oncology nurse isn’t a job; it’s a calling and a passion. We’re here for our patients for all the highs and lows they’re experiencing.”

On the Future
Davis is currently working on completing her BSN. She’s excited to be done in April, but more excited to continue her education to become a Nurse Practitioner.

“I enjoy volunteering and helping people. My faith also plays a strong role in my caregiving. I look forward to working on mission trips in the future where I can help patients heal both physically and spiritually. There’s such a need for healthcare in both our rural community and communities abroad.”


In my time speaking with Shirley Davis, it became clear that she exemplifies what it means to be a nurse. Her desire to continue her nursing education, her love for her patients, and her devotion to improving the world around her, make a shining example of what it means to go above and beyond the call of care.

Contributed by PESI Social Correspondent Josie Salzman.


Attachment-1Shirley Davis, R.N., has a passion for life. When she’s not caring for her patients, you may find her mountain biking and taking in nature. For Shirley’s role as on oncology nurse, PESI recognizes her as a dedicated nurse.


Do you know a nurse who deserves recognition for going above and beyond the call of care? Tell us about it.


Get a free hour of CE when you watch Mastering the Neurological Assessment with Cyndi Zarbano.

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Out of the Tunnel: A Series on escaping the path of depression—Part 1

What happens when you ask your depressed client to help you map out not only the contours and geography of their suffering but also their competence and better moments? You get a new strategy for treating depression: marbling.

Join us for part one of our two part exploration of “marbling” from expert Bill O’Hanlon.

This if the first part of our series on depression treatment written by Bill O’Hanlon, MS, LMFT


In recent years, we’ve learned that repeating patterns of experience, attention, conversation, and behavior can “groove” the brain; that is, your brain gets better and faster at doing whatever you do over and over again. This includes “doing” depression, feeling depressed feelings, talking about depression, and so forth. Thus we can unintentionally help our clients get better at doing depression by focusing exclusively on it.

To counter this effect, I like to use a method that I call “marbling.” My father owned several meat-packing plants, and early on I learned that marbling refers to the fat streaks embedded in the leaner meat in a cut of steak. It gives the steak more flavor. In a similar way, but with less cholesterol, in therapy I suggest marbling discussions and evocation of non-depressed times and experiences in with discussion of depressed times and experiences. By going back and forth between investigations of depressed and non-depressed experiences and times, the person who’s been depressed is reminded of resources and different experiences, and often begins to feel better during the conversation.

In this three part series, we will explore various ways of incorporating marbling to discover more about your clients individual depression map.

One Foot In

Working with people who are depressed requires a delicate balance. They’re usually lost in their depressive experience and perspective, so you have to join them in that experience and let them know you have some sense of what they’re going through. At the same time, you have to be careful not to get caught up in that discouragement and hopelessness along with them.

I think of it as having one foot in their experience and one foot out. I call this Acknowledgement and Possibility. It involves acknowledging the depressed person’s suffering, validating his felt sense of things, and inviting him out of that experience.

When people don’t feel heard, understood, or validated in their experience, they often appear “resistant” and uncooperative in therapy. On the other hand, if all one offers is acceptance and validation, it’s all too easy to help the sufferer wallow and stay stuck in his depressive experience.

I remember a client I had early in my psychotherapy career who’d come in week after week soaking up my kind acceptance, unconditional positive regard, and empathy. She’d get her weekly support session and then go back to her miserable life. During one session-it was probably about our 22nd-I heard myself saying, “So, you’re depressed again this week.” And realized I wasn’t really helping her.

Around that time, I began to study with the psychiatrist Milton Erickson, who had many creative ways of challenging the most difficult patients to move on and change. I began to incorporate some of his methods into my work and noticed that my clients were changing much more quickly than they had before. But I still liked the warm, kind, active listening I’d learned in my elementary counseling training and didn’t want to lose that respectful approach. So I combined the best of both worlds and created this Acknowledgment and Possibility method. It not only respectfully acknowledges the person’s painful and discouraging experiences, but also gives him a reminder that he isn’t always and hasn’t always been depressed. It can illuminate and prompt skills, abilities, and connections that can potentially lead the person out of depression or at least reduce his depression levels.

I came across a letter that Abraham Lincoln wrote during his presidency that illustrates his deft combination of joining and inviting. (Lincoln suffered from a lifelong tendency toward depression, or what was called melancholy in those days. He’d been close to suicide during two major depressive episodes in his younger years.) He found out that Fanny McCullough, the young adult daughter of one of his generals who’d been killed during the Civil War, had fallen into a depression that was lasting much longer than the usual grief period. She’d taken to her bed in despondency, and her loved ones were worried about her.

When Lincoln heard of her plight, he sat down and wrote the following letter. (Note: I’ve italicized some of the Acknowledgment and Possibility parts of the letter to highlight them.)

Dear Fanny,

It is with deep grief that I learn of the death of your kind and brave Father; and, especially, that it is affecting your young heart beyond what is common in such cases. In this sad world of ours, sorrow comes to all; and, to the young, it comes with bitterest agony, because it takes them unawares. The older have learned to ever expect it. I am anxious to afford some alleviation of your present distress. Perfect relief is not possible, except with time. You cannot now realize that you will ever feel better. Is this not so? And yet it is a mistake. You are sure to be happy again. To know this, which is certainly true, will make you some less miserable now. I have had experience enough to know what I say; and you need only believe it to feel better at once.

What’s so moving about this letter is the kind and powerful way Lincoln joins with Fanny’s grief and validates her suffering while simultaneously inviting her out of it.

Three Techniques of Acknowledgement and Possibility

How do you join while simultaneously inviting? Here are three simple methods for putting one foot in and one foot out when talking with people who are depressed.

1. Reflect in the past tense. This technique may seem too simple, but it can have a subtle and helpful impact. It involves reflecting what the depressed person is telling you as if it has happened previously but is not necessarily occurring now. For example, if a person says, “I don’t want to see anyone,” you might respond, “You haven’t wanted to see anyone.” If the person says, “I’m suicidal,” you might say, “You’ve thought seriously about killing yourself.” In each of these responses, you’ll notice that the reflection is couched in the past tense.

Here are two statements that a depressed person might make, along with some sample “reflect in the past tense” responses.

Depressed person: “I’m afraid I’ll never come out of this darkness.”

Possible responses: “You’ve been really afraid.” “You’ve been feeling pretty discouraged.” “You’ve been worried you’ll never feel better.”

Depressed person: “Nothing will help.”

Possible responses: “Nothing has helped.” “You’ve tried a lot of things and haven’t felt better.” “You’ve been thinking that nothing will help.”

2. From global to partial reflections. The next technique for acknowledging and inviting at the same time is to reflect the depressed person’s generalized statements as more partial. When the person says something like “always,” “never,” “nobody,” “nothing,” “everybody,” or another global term, you can reflect her statement or the feeling she’s conveying but using more limited words, such as usually, typically, rarely, almost nobody, very few people, little, most everyone, and so on. Your task here is to help her feel understood, but at the same time to introduce a little space into the stuck place she feels herself to be in.

Your reflections can be less global than the person’s original statement in both time (lately, recently, these days) and quantity (most, very few, almost everyone, little, rarely). For example, if the depressed person says, “Nothing is helping,” you might respond with, “You’ve tried most everything and it hasn’t worked much.”

3. Validating perceptions but not unchanging truth or reality. To use this technique, acknowledge and validate the depressed person’s perceptions without accepting the fixed, objective truth or unchanging reality of those perceptions.

When people are depressed, they often have an unrealistically pessimistic view of life, so agreeing with that pessimistic perspective may further discourage them. But we can’t just dismiss the person’s felt experience and tell her that her point of view is wrong. This technique involves finding a crucial balance by joining with and validating the person’s felt sense of the way things are while separating those views from accepted reality.

To do this, use phrases such as your sense; as far as you can see; as far as you remember; the only way to handle this, in your view, was; and so on. The goal is to help the person feel heard and understood without joining in her distorted or discouraged conclusions.

Here’s another example of a statement a depressed person might make, along with some suggested responses.

Depressed person: “I’ll never get better.”

Possible responses: “You think you won’t get better.” “Your sense is that there’s not much hope.” “As far as you can tell, nothing’s been working and you’re afraid nothing will.”

Combining All Three Techniques

Of course, as you get more practiced at these techniques, you can combine two or three of them in the same reflection. For example, if the person says, “I’ve just got to kill myself. I can’t take this anymore,” you could use all three techniques in your response by saying, “So, you’ve really been so discouraged lately and suffering so much that killing yourself seems the best possibility for relief right now.”

However, if the person gives you the sense that she feels invalidated or that your response minimizes her experience or suffering, you can switch to another of the techniques or return to pure acknowledgment for a time, leaving out any of the possibility elements.

For instance, suppose the person says, “I can’t get up and going,” and you use the partial reflections technique and respond with, “Sometimes getting going is really hard for you.” What do you do if the person comes back with, “Not sometimes. Every damn day! You just don’t get it, do you?”

You could respond with, “Sorry, I didn’t mean to minimize what it’s like for you to struggle with this. And you’re right, I probably don’t fully get how things are for you. So, your sense is that you can’t get going pretty much every day.”

The person will often respond with something like, “Well, on the days I see you, I manage to get up, but the other days it just feels too hard.” And that is the beginning of possibility. Your task in using these techniques is to stay close to the person’s experience while introducing small openings into her discouragement and sense of hopelessness. She’ll let you know when those possibilities start to become viable and real for her when she begins talking about possibilities and change herself.


Coming soon: The finale to our exploration of marbling depression.


For the past 30+ years, Bill O’Hanlon, MS, LMFT, has given over 2,000 talks around the world and was awarded the Outstanding Mental Health Educator of the Year in 2001 by the New England Educational Institute. He is a Licensed Mental Health Professional, Certified Professional Counselor, and a Licensed Marriage and Family Therapist. An accomplished author, Bill is known for his storytelling, irreverent humor, clear and accessible style and his boundless enthusiasm for whatever he is doing.


This post is based on an article originally brought to life by our partner, Psychotherapy Networker.

The full article, “Out of the Tunnel: Escaping the Trance of Depression” written by Bill O’Hanlon, appeared in the Nov/Dec 2014 issue of Psychotherapy Networker magazine.