This week I’m back to reviewing the page proofs for the 6th edition of Clinical Interviewing. It’s tons of fun. I’m consistently surprised when I find typos or bad sentences in material that I’ve already reviewed five times previously. Ugh. Oh well. Life is generally good . . . and once in a while I run into some interesting new content that I think is worth sharing. Here’s one excerpt. It’s toward the end of Chapter 4, titled: “Nondirective Listening Skills.” The 6th edition is coming soon: https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=sr_1_5?s=books&ie=UTF8&qid=1470784556&sr=1-5&keywords=clinical+interviewing
Ethical and Multicultural Considerations
It’s likely that each client will respond to you and your listening skills differently. Some clients will love having you as a listener. They’ll be instantly impressed with your excellent interviewing skills. Other clients will be neutral. Still others will think (and possibly tell you) that your education and training are worthless and that they resent having to spend time with you.
The Ethics of Not Directing
Listening well is an essential therapeutic skill, but many clients don’t come for counseling looking for an excellent listener. They come because they want an expert. They desire guidance. They may even want to be told what to do and how to do it.
The desire for an authoritative counselor may be particularly salient within ethnic and cultural groups. For example, Asian American clients tend to want more direct guidance from their counseling professionals (Chang & O’Hara, 2013). Of course this is a generalization, but knowing that some Asian clients want an expert and will be disappointed if you don’t act in more directive ways is valuable information.
Some presenting problems, such as those present in crises or severe mental disorders, also might require more active and directive interventions. Cultural and personal expectations, presenting problem(s), and theoretical orientations can call for more directive, authoritative interactions. If so, it might be unethical for you to persist with nondirective listening and not advance to the skills and techniques described in Chapters 5 and 6. See Case Example 4.2 for a concrete example.
Case Example 4.2: When Being Nondirective Might Be Unethical
While reading the referral information, you discover that your new client is a seventeen-year-old Chinese American female with a history of cutting and parasuicidal behavior. Early in the interview she tells you, “I want to stop cutting.” This is especially good news because you know something about skills training for clients who cut. Although your active listening provides an excellent foundation, if you only listen to her, you’ll be doing her a disservice. The point is this: If you know about something that fits with your client’s specific condition and you withhold it without an exceptionally good rationale, you’re in ethical hot water. In this case, you should actively begin teaching your client alternative emotional management skills.
In another situation, you could make a case for withholding your advice and being less direct. For example, if your client is Native American and rapport development is slow and you’re not certain that she’s motivated to stop cutting, you would have a solid rationale for maintaining a nondirective listening stance with plenty of self-disclosure and a focus on developing a working alliance. Staying less direct with Native clients and respecting their process are reasonable strategies. Your client might not be ready or willing to work on developing alternative coping strategies until session 2 or 3 or 4. If you were to jump in too soon with advice on how to stop cutting, your client might not show up for session 2.
Gender, Culture, and Emotion
Imagine that you’re in an initial clinical interview with a Latino male. Your impression is that he’s angry about his wife’s employment outside the home. You’re aware that some Latinos have more traditional ideas about male and female roles in the home. This knowledge provides you with evidence to support your hypothesis about your client’s emotional state. So you intentionally use a reflection of feeling to focus in on your client’s anger:
I’m getting the sense that you’re a little angry about your wife deciding to go back to work.
Nah. She can do whatever she wants.
You hear his words. He seems to be empowering his wife to do as she pleases. But his voice is laden with annoyance. This leads you to try again to connect with him on a deeper level. You say,
Right. But I hear a little annoyance in your voice.
This reflection of feeling prompts an emotional response, but not the one you had hoped for.
Sure. You’re right. I am annoyed. I’m fucking annoyed with you and the fact that you’re not listening to me and keep focusing on all this feelings shit.
This is a dreaded scenario for many clinicians. You take a risk to reflect what seems like an obvious emotion, and you get hostility in return. For several possible reasons, your emotional sensitivity backfires. The client moves to a defensive and aggressive place, and a relationship rupture occurs (see Chapter 7 for more on dealing with relational ruptures).
It’s tempting to use culture and gender to explain this client’s negative reaction to your reflection of feeling. But it’s not that simple.
Although culture, gender, race, and other broad classification-based variables can sometimes predict whether a specific client will be comfortable with emotional expression, individual client differences are probably more substantial determinants. In particular, comfort in expressing emotion is often a function of whether the client comes from a family-neighborhood-cultural context where emotional disclosure was a norm. For example, Knight (2014) reported that black and Latino males who were unlikely to disclose to their peers attributed this tendency directly to their experiences living in violent communities. These young men had learned that emotional expression and trusting others were bad ideas in their neighborhoods. Conversely, emotional disclosure is more likely to be in the comfort range of black and Latino males who are raised in safer community environments. This makes good common sense: Whether clients perceive you as safe to talk with about emotional concerns probably has more to do with the clients’ background and past experiences than it has to do with you.
Overall, it’s likely that clients’ willingness to tolerate feeling reflections is based on a mix of their cultural, gender, and individual experiences. To move these ideas toward application, if you have reason to suspect that your client is less comfortable focusing on emotions, you should avoid words that are emotionally specific and therefore more provocative. Examples of emotionally specific words include angry, sad, scared, and guilty.
Instead of using emotionally specific words, you can initially substitute words that are emotionally vague (and less intense). Later, as trust develops, it may be possible to use more specific emotional words. Consider the following phrases:
- You found that frustrating.
- It seems like that bothered you a bit.
- It’s just a little upsetting to think about that.
Putting It in Practice 4.4 lists examples of emotionally vague words you might use instead of emotionally specific words.
Putting It in Practice 4.4: Using Vague and Emotionally Safe Words
Emotionally Specific Words Substitute (Safer) Words
Angry Frustrated, upset, bothered, annoyed
Sad Down, bad, unlucky, “that sucked”
Scared Bothered, “didn’t need that,” “felt like leaving”
Guilty Bad, sorry, unfortunate, “bad shit”
Embarrassed Less than comfortable, bugged, annoyed
Note: These words may work as substitutes for more emotionally specific words, but they also may not. It will be more effective for you to work with your classmates or work setting to generate less emotionally threatening words and phrases that are culturally and locally specific.