Texting: The Third Client in the Room

Dubus (2015) presented a case study example of the utilization of texting in the psychotherapy process with an adolescent female and her father during family therapy sessions. The goals of the article were to highlight generational differences, explore the meaning of text messaging for adolescents, and discuss the utility of texting within sessions. Dubus (2015) concluded with recommendations for future research to enhance understanding of best practice with clients in the current digital environment.


The article noted there are generational differences, including knowledge of popular culture, media events, and age-specific experiences, that can influence therapeutic relationships between a therapist and client (as well as multiple family members during family therapy) in psychotherapy. Dubus (2015) cited Kennedy et al. (2010) to point out that adolescents are “native” to the digital world. In their lifetime, they have been surrounded by digital technology and were born into a world where digital technology already existed. By contrast, individuals of older generations, labeled in the article as digital “immigrants,” may have developed their social identities before digital technology was introduced. Therefore, adolescent clients and psychotherapists or mental health professionals may find themselves on different pages or on either side of this digital divide.


While some studies have warned about challenges related to digital technology, including issues related to confidentiality, others have highlights the benefits. Although she did not provide specifics, Dubus (2015) mentioned studies that have reported “the use of digital communication as an effective treatment venue and as a form of intervention.” However, Dubus (2015) raised some important questions: “What are the rights, responsibilities, and risks for both the client and provider when a client introduced test messaging within the counseling setting?” “For a minor, who has a right to see the text messages written during therapy sessions?” “What are the implications of cell phone use in the counseling room?” and “What dynamics does it introduce?”


Frank (2010) found that nearly 20% of adolescents send more than 120 text messages per day during their school day (as cited by Dubus, 2015). Dubus (2015) discussed texting as a coping skill for adolescents, a way for them to develop and maintain social relationships and supports, as well as a means of connecting with family members.


Case Illustration
Dubus (2015) described a family therapy scenario with a father, Bob, and his 15 year-old daughter, Megan. The background information provided included that Megan’s mother (Bob’s wife) had died of cancer three years prior and that Megan’s brother (Bob’s 19 year-old son) had recently left home for college. Bob and Megan relationship could be described as strained, with Bob describing Megan as “disobedient” and Megan describing Bob as “critical.” Megan was reportedly very close with her mother prior to her death. Megan and Bob were going to psychotherapy per Bob’s request, as he felt he was having a difficult time getting along with his daughter.  Megan was initially resistant to attending.


During the first session, Megan expressed her frustration with her father being critical and unavailable. In response, Bob stated Megan was never around and that she didn’t listen to him. As Bob talked, Megan apparently turned away from her father and began texting. Dubus (2015) acknowledged that in that moment, the therapist had a few options, including asking Megan to put away the phone, commenting about the texting, or not to say anything. The therapist chose not to address the texting. She allowed Megan to continue to text, feeling the texting was serving Megan in some way. Bob did not mention the texting either.


Over the next few sessions, the therapist noted Megan began to text when she was feeling criticized by her father. The therapist was aware that by mentioning the texting there was a risk of Megan feeling further criticized by another adult in the therapy sessions. Furthermore, the therapist felt Megan almost left the room at times out of frustration with her father and that the texting provided Megan with a buffer and she stayed in the room. Overtime, Megan and Bob’s relationship began to mend and the therapist noted Megan texted less during the sessions. By the sixth and seventh sessions, Megan apparently did not use her phone at all.


Dubus (2015) pointed out that Megan seemed to use the texting to maintain a sense of connection when she was feeling disconnected from her father. Barak and Grohol (2011) and Ling et al. (2012) found adolescents will text in churches and classrooms as well as other environments where even college age young adults will not (as cited by Dubus, 2015). Texting is seemingly a cultural norm for today’s adolescents and will likely continue to be for future generations (until, of course, there is new technology). Many therapists would have handled the same situation differently; however, the therapist in this example seemed to put herself in Megan’s shoes and attempted to understand the purpose the texting served for Megan. The last line of the article was well stated, it read, “As counselors, therapists, social workers we will continue to meet the client were they are at, and that may be with technology.”


Dubus, N. (2015). Texting: The third client in the room. Clinical Social Work Journal, 43 209-214. doi: 10.1007/s10615-014-0504-3


Brittany Best, MA
WKPIC Doctoral Intern

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Friday Factoids: New Insights Into Violence Related to Mental Illness



Past research indicates that mental illness is noted to be a modest risk factor for violence, with only 4% of violence in the United States attributed to individuals with mental illness”(Monahan et al., 2001 and Swanson, 1994, as cited in Skeem, Kennealy, Monahan, Peterson, & Appelbaum, 2015).  Rather, violent acts committed by individuals with mental illness is only associated with a fraction or a small subgroup of this population.


Unfortunately, little is known about how often and how consistently high-risk individuals with mental illness experience delusions or hallucinations prior to violent acts (Skeem et al., 2015).  Thus, in order to determine if psychosis preceded violence, Skeem, Kennealy, Monahan, Peterson, and Appelbaum (2015) used data from the MacArthur Violence Risk Assessment study to examined 305 violent incidents committed by 100 former inpatients.


Results indicated that in 12% of the 305 incidents, delusions and hallucinations immediately preceded the act.  Also the data indicated that for a large portion of the sample, violence was consistently not preceded by psychosis (80%) whereas a smaller group of individuals reported some psychosis-preceded violence (20%). Again, this suggests that within the sample, groups can be disaggregated into the majority with non-psychosis preceding violence from those with psychosis-preceding violence.


This study does not indicate a causal link between psychosis and violence; rather, it indicates a relationship or temporal ordering for these events.  Overall, the data indicate that psychosis sometimes preceded violence for high-risk individuals.  Yet, psychosis-preceded violent acts tend to be concentrated within a subgroup of high-risk patients.  Treatment implications note that for individuals with psychosis-preceded violence, delusions and hallucinations should be a focus of treatment targeting violence prevention.  Even still, providers must consider other precipitating factors associated with violence.


Skeem, J., Kennealy, P., Monahan, J., Peterson, J., & Appelbaum, P. (2015). Psychosis uncommonly and inconsistently precedes violence among high-risk individuals. Clinical Psychological Science. Advance Online Publication. doi: 10.1177/2167702615575879



Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
WKPIC Practicum Trainee




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Congratulations to Brittany Best!!



WKPIC extends kudos to current intern Brittany Best for her successful dissertation defense this week. WAY TO GO!!! You’re almost across that finish line!





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Friday Factoids: Cognitive Behavioral Therapy for Insomnia

Insomnia has a high prevalence rate, with 5% to 15% of adults meeting diagnostic criteria (Trauer, Qian, Doyle, Rajaratnam, & Cunnington, 2015).  The impact is not limited to nighttime problems; rather, it can be considered a 24-hour problem that is known to affect functioning throughout the day (Morin, 2015).  Furthermore, insomnia is also a significant risk factor for adverse health, psychological, and occupational problems (Morin, 2015).


Insomnia has been linked to anxiety and depression (Trauer et al., 2015). Often solutions or treatment of insomnia are related to pharmacological aid, with approximately 6-10% of adults in the US using hypnotics in 2010 (Trauer et al., 2015).  Yet, given concerns of side effects and addictive properties of benzodiazepines, alternative interventions are being studied.  Specifically, Cognitive-Behavioral Therapy for insomnia (CBT-i) has been shown to be an effective alternative to pharmaceuticals.


In general, CBT-i has five components:  Cognitive Therapy, focusing on identifying negative beliefs about sleep and explaining how these beliefs relate to insomnia, then identifying alternative thoughts; Stimulus Control, attempting to maximize the association between the bed and sleep through behavioral changes (e.g., avoiding stimulating activity in the bedroom, such as watching television or using the computer); Sleep Restriction, behavioral instruction advising patients to only go to bed when sleepy in order to minimize lying awake time; Sleep Hygiene, educating and discussing good sleep practices (e.g., avoid daytime naps); and finally, Relaxation, teaching relaxation skills to use before bed (Trauer et al., 2015).


To investigate the efficacy of CBT-i, Trauer, Qian, Doyle, Rajaratnam, and Cunnington (2015) completed a systematic review and meta-analysis to examine the outcome of CBT-i compared to pharmacological interventions.  Results indicate that after participating in CBT-i, patients fell asleep faster (19.03 minutes), spent less time awake in the middle of the night (26 minutes less), got more sleep overall (increase of 7.61 minutes), and improved self-efficacy about sleep by 9.91 percent. The authors concluded that CBT-i demonstrated similar levels of improvement compared to benzodiazepines for treatment of insomnia (Trauer et al., 2015). Of note, the authors did not compare CBT-i to other sleep aids (i.e., Z drugs or non-benzodiazepines [Lunesta, Ambien]), due to limited data regarding the long-term effects of such medications.


Overall, CBT-i was noted to be more sustainable overtime compared to pharmacological treatment and reported no adverse outcomes.  Given that CBT-i requires more effort and commitment when compared to taking a pill, it becomes necessary to determine if CBT-i has a beneficial impact on quality of life, fatigue, and psychological distress (Morin, 2015).  Ultimately, these findings demonstrate the efficacy of CBT-i and provide patients with a choice regarding treatment for insomnia.


Morin, C. M. (2015). Cognitive behavioral therapy for chronic insomnia: State of the science versus current clinical practices. Annals of Internal Medicine. Advance online publication. doi: 10.7326/M15-1246


Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M. W., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine. Advance online publication. doi: 10.7326/M14-2841


Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
WKPIC Practicum Trainee

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The Role of a Recovery Story in Peer Support

The sharing of one’s “Recovery Story” is the foundation upon what the rest of peer support is built.  A Recovery Story is the telling of the personal journey the Peer Support Specialist has been on in order to reach the point of health and integration into the community, or whatever “recovery” means to that person.  A Recovery Story is different than a story about one’s illness.


BrightA story simply about one’s illness concentrates on the negative aspects of mental illness and only about the struggles.  A Recovery Story shares the challenges faced, sometimes the tragedies, at times the struggles with symptoms or diagnoses, but it leads to a point of positive conclusion.  A Recovery Story shared gives hope to another individual, and lets another person know that one should never give up on the possibilities that life has to offer.


I share parts of my story every day; I share the good and the bad experiences.  I share the tragedies and the triumphs.  I share what I did or how I reacted in certain circumstances.  I tell about the symptoms that I exhibited in the most difficult times of my illness.  Sharing this story puts the other person at ease and lets them know it is okay to open up and talk about their own experiences.  Every once in a while, it may give another person hope that it is not only possible to get better, but it is expected that they will eventually live a full and productive life.


Rebecca Coursey, KPS
Peer Support Specialist


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Friday Factoids: Does the “H” in ADHD Really Impair Learning?

Recent models of Attention-Deficit Hyperactivity Disorder (ADHD) have challenged the notion that excess gross motor activity (hyperactivity) impedes learning with children diagnosed with ADHD.  Rather, newer models argue that excess motor activity may be compensatory.


A recent study conducted by Saver, Rapport, Kofler, Raiker, and Friedman (2015) compared 29 boys diagnosed with ADHD to 23 boys with no psychiatric diagnosis on a series of working memory tasks (i.e., participants were shown numbers and letters on a computer screen and asked to order them, while being recorded on a high speed camera for later behavior/movement coding).  The data indicated higher rates of gross motor activity positively predicted phonological working memory performance in children with ADHD.  Such was not seen in children with no psychiatric diagnoses.  In fact, boys with no ADHD diagnosis with increased movement performed more poorly on the cognitive tasks.  Thus, indicating a link between hyperactivity and task performance in children with ADHD.


Saver et al. (2015) conclude that excess movements are necessary to how children with ADHD remember information and process cognitive tasks.  The implications here are vital to recommendations given specific to behavioral intervention and current classroom management of behavior for children with ADHD.  In that, if these findings are confirmed, the authors caution against overcorrecting excess gross motor activity for children with ADHD.   Such activity may even be reinforced during select academic tasks.  Of course, the authors do not recommend allowing extreme movements (e.g., running around the room); rather they argue to facilitate movement in order to maintain alertness to complete cognitive tasks (University of Central Florida, 2015).


These findings implicate that past behavior plans and expectations/goals of reduced activity may be misguided, instead movement perhaps should be permitted in order to maintain alertness.  Overall, data support a new conceptualization that gross motor activity may facilitate cognitive functioning for children with ADHD, rather than impair it.  This research is limited by only sampling boys ages 8-12.  It is further limited by only assessing phonologically based activity; future research is anticipated to look at the impact of hyperactive movement in relation to visuospatial working memory (Saver, Rapport, Kofler, Raiker, & Friedman, 2015).  Overall, these finding again support new models of ADHD that conceptualize excess motor activity as compensatory.


Sarver, D. E., Rapport, M. D., Kofler, M. J., Raiker, J. S., & Friedman, L. M. (2015). Hyperactivity in attention-deficit/hyperactivity disorder (ADHD): Impairing deficit or compensatory behavior? Journal of Abnormal Child Psychology. Advanced online publication. doi: 10.1007/s10802-015-0011-1


University of central Florida. (2015). Kids with ADHD must squirm to learn, study says. Retrieved from www.sciencedaily.com/releases/2015/04/150417190003.htm


Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
WKPIC Practicum Trainee

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Friday Factoid: Preventing Early Termination of Therapy


Dropout and early termination in therapy is a concern for many practicing psychologists or therapists.  Research indicates that 20 percent of clients will terminate therapy prematurely (Chamberlin, 2015).  Furthermore, Swift and Greenberg (2012) found that one in five clients will dropout before completing therapy.  So the question becomes, what are the common reasons for early termination and what can the practitioner do to influence this trend?  Briefly, according to Dr. Greenberg (as cited in Chamberlin, 2015) some of these common factors could be easily addressed.  For example, clients may have unrealistic assumptions about therapy or they may not fully understand the roles of client or therapist.  They also may not understand the timeline or commitment needed.  Additionally, some clients may have more practical problems, such as childcare or transportation difficulties.  Finally, clients may experience anxiety about discussing feelings and/or traumatic, emotional experiences.


In their book, Premature Termination in Psychotherapy, Swift and Greenberg offer eight empirically supported strategies (listed below) to help clients stay on track.

  1. Provide role induction.  Here the clients are offered education on the process of therapy, as well as, clarify client and therapist expectations.
  2. Incorporate client preferences into the treatment decision-making process.  This will help balance treatment options and will foster a client’s investment in therapy.
  3. Help plan for appropriate termination.  Provide an estimated timeline for treatment; also allow open discussion about termination and endpoints that indicate the end of therapy.
  4. Provide education about patterns of change.  Preparing clients for emotional setbacks is necessary, as well as discussing the initial improvements and thinking therapy is done.
  5. Strengthen early hope.  Hope fosters commitment, and as a result, clients are more likely to continue and work past setbacks.
  6. Enhance motivation for treatment.  Address motivation from session to session; utilizing techniques of motivational interviewing may also help clients remain in therapy.
  7. Foster the therapeutic alliance.  Foster and develop basic therapeutic skills, as well as monitor and repair ruptures in the alliance.
  8. Discuss treatment progress with your clients.  Providing feedback through discussion or objective self-report may help gauge progress and identify problems before clients dropout.


Overall, the strategies listed above provide simple interventions that have shown to mitigate dropout rates.  Often these strategies are not emphasized in training, but have shown to be effective in helping clients remain in treatment.


Chamberlin, J. (2015).  Are your clients leaving too soon? Monitor on Psychology, 46(4), 60-63.


Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80, 547-559.


Swift, J. K., & Greenberg, R. P. (2014). Premature termination in psychotherapy: Strategies for engaging clients and improving outcomes. Washington DC: American Psychological Association.


Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
WKPIC Practicum Trainee



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The Role of Wellness Recovery Action Plans in Recovery


Wellness Recovery Action Plans or “WRAP” were developed by Mary Ellen Copeland, PhD, after years of research and her own personal fight with what was then called manic depression.  She learned coping skills which helped her begin to live a productive life, but not before experiencing hospitalizations and many trials and errors of medications.  Her struggles sound very familiar.  She developed a plan which outlined triggers, symptom monitoring, patient rights issues, and personal supports.


The WRAP is a tool which covers the key concepts of recovery: hope; personal responsibility; education; self-advocacy; and support.  One section of it is called the “Crisis Plan” and is extremely relevant to someone who finds him/herself hospitalized.  Sitting down with a patient and completing this plan puts a diagnosis in perspective.  It covers descriptions of when the patient is feeling well, symptoms that show that he or she may no longer be able to make decisions on his or her own, what person should take over at that time, and what person should NOT take over at that time.


The WRAP also covers patient right issues.  It goes over acceptable medications and unacceptable medications, asking also for reasoning.  The WRAP states treatments that are okay, facilities that are preferred if hospitalization is needed, and what the person needs his or her supporters to do if a hospitalization occurs.  It really covers everything that a person may not be able to communicate when in a crisis situation.


The WRAP is connected to a copyrighted workbook.  There are generic versions available.  If one were to make a basic outline with the issues discussed, that may be enough to help a person develop a plan for the future.


Rebecca Coursey, KPS
Peer Support Specialist

“Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”        SAMHSA

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Friday Factoids: Is “Hangry” Really a Thing?

Most people have heard the new and popular term “hangry,” but what does it really mean? Do people really feel angry just because they are hungry? Absolutely!


If you haven’t experienced this feeling yourself, you may have been around a spouse, parent, child, or friend when they were hungry and seemed to be needlessly angry. Research has also been done to confirm people do get “hangry” when they’re in need of some food.


In one interesting study, participants were given the opportunity to blast their partners with loud, irritating noises or to stick pins in a voodoo dolls representing their spouse. The study found the lower the level of glucose in the participants’ blood (glucose is derived from the food we eat and low levels can indicate the body has used up its food) the higher the intensity and long duration of the noise they gave to their spouse and the greater number of pins they stuck into the voodoo doll. In fact, “people with the lowest blood sugar levels stuck more than twice as many pins in the voodoo dolls compared to people with the highest levels.”


Van Buren, Alex. (2014). “Hangry is a real thing.” Retrieved from https://www.yahoo.com/food/hangry-is-a-real-thing-82802959390.html


Brittany Best, MA
WKPIC Doctoral Intern





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Compassion Fatigue

As a Peer Support Specialist, I have to be very cautious about taking care of myself.  Yes, I am in recovery, but I am not cured. I still have what is considered a serious mental illness.  If I were to forget to take my medication for a few days or go without sleep, the symptoms of Bipolar could return.  Stress is also a major factor.  Therapy while working in a full-time job position is very important to my health.


I recently attended a conference for Peer Support Specialists across the state.  I attended a workshop entitled, “Compassion Fatigue.”  Occupations in which people must work with those who are experiencing trauma can experience this.  Emergency room nurses, mental health clinicians, social workers, Peer Support Specialists, and other fields in which compassion is a constant job requirement can experience Compassion Fatigue.  One woman told her story of such an experience.


Some of the symptoms of this fatigue, according to the Compassion Fatigue Awareness Project, are “apathy, bottled up emotions, substance abuse, and isolation from others.” In an organization or institution, the fatigue can result in:

  • High absenteeism
  • Constant changes in co-workers relationships
  • Inability for teams to work well together
  • Desire among staff members to break company rules
  • Outbreaks of aggressive behaviors among staff
  • Inability of staff to complete assignments and tasks
  • Inability of staff to respect and meet deadlines
  • Lack of flexibility among staff members
  • Negativism towards management
  • Strong reluctance toward change
  • Inability of staff to believe improvement is possible
  • Lack of a vision for the future


When I first began seeing my therapist, he said I came into his office in terrible shape.  The point is…I got better, but it took work.  Therapy is awesome and I think anyone can benefit.  I definitely have, and I talk about how it helped me to my peers, (the patients), in the hospital.


Rebecca Coursey, KPS
Peer Support Specialist


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