I’m virtually in Vermont tomorrow doing an all-day-long workshop on working with so-called challenging youth in counseling and psychotherapy. We start at 8am Mountain Time . . . and 10am on the East coast. Here’s the link to register for the workshop for anyone who suddenly has found themselves with a wide open day. The cost is: $195.
My wife (Rita) and I used to argue over who came up with the catchy “Tough Kids, Cool Counseling” title for our 1997/2007 book with the American Counseling Association. I would swear it was MY grand idea; she would swear back that it was HER idea. If any of you are in–or have been in–romantic partnerships, perhaps you can relate to disagreements over who has all the best ideas. I doubt that this dynamic is unique to Rita and me.
Years passed . . . and now I’ve come to very much dislike the title. . . leading me to give Rita ALL THE CREDIT! You’ve got it Rita! It was all you!
Despite my dislike for the title, I still sometimes use it for workshops. Why might that be, you may be wondering? Good question. I use it so I can make the point, early in the workshop, that we should NEVER use language that blames young people for their problems or their problem behaviors. In fact, we should never even “think” thoughts that assign blame to them for being “tough.”
My reasoning for this is informed by constructive theory and narrative therapy. When we assign blame and responsibility to young people for being “tough” or “difficult” or “challenging,” we risk contributing to them holding a tough, difficult, or challenging identity–which is exactly the opposite of what we want to be doing. Instead, I tell my workshop participants that we should recognize, there are no “tough kids” . . . there are only kids in tough situations . . . and being in counseling or psychotherapy is just another tough situation that young people have to face. Consequently, it’s NOT their fault if they engage in so-called tough or challenging behaviors.
All this leads me to share that I’ll be online all day on December 6, 2024, doing a workshop for mental health professionals. The workshop, anachronistically titled, “Tough Kids, Cool Counseling” is sponsored by the Vermont Psychological Association. You can register for the workshop here: https://twinstates.ce21.com/item/tough-kids-cool-counseling-131540
Even if I do say so myself, I’m proclaiming here and now that this will be a very engaging online workshop. If you work with youth (ages 10-18) in counseling or psychotherapy, and you need/want some year-ending CEUs, we’ll be having some virtual fun on December 6, and I hope you can join in.
During my supervision this week, I noticed that the concepts and process of Motivational Interviewing came up several times. When students or professionals don’t know the basics of Motivational Interviewing (MI), I feel compelled to speak up. MI is a method, strategy, or philosophy that’s complex, nuanced, and essential. We should all know about and have MI skills. To feel the centrality of MI to counseling and psychotherapy, it helps to start with MI’s most fundamental organizing principle.
“It is the client who should be voicing the arguments for change” (Miller & Rollnick, 2002, p. 22).
If you contemplate this principle (and you should), then you’ll need to examine your own role in the change process. That’s because, if look at (or listen to) yourself, and YOU’RE the one voicing the arguments for change, you must stop.
If you don’t stop, then you may be contributing to your clients’ resistance to change.
MI ideas are challenging to our natural impulses. We want to tell clients how to be healthier, but our job is not to voice the argument for positive and healthy change; our job is to nurture their argument for positive and healthy change. This is where the nuance comes in. How can we, as interviewers (aka counselors or psychotherapists) create an interaction wherein the client is more likely to take the lead in voicing the arguments for positive and healthy change?
The answer to that question is complex, as it should be. In part, my answer today is to include an excerpt from Chapter 12 (Challenging Client Behaviors and Demanding Situations) of our Clinical Interviewing text. This excerpt starts with the topic of “Challenging Client Behaviors” or behaviors that clients engage in that counselors and psychotherapists often find challenging. The content includes a discussion of the concept of “resistance,” MI strategies, as well other ideas of our own and from the literature.
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Challenging Client Behaviors
As the client and therapist talk more and more about the solution they want to construct together, they come to believe in the truth or reality of what they are talking about. This is the way language works, naturally.
—Insoo Kim Berg and Steven de Shazer, Making numbers talk, 1993, p. 6
Not all clients are equally cooperative. Here are a few opening lines we’ve heard over the years:
Do I have to be here?
No disrespect, but I hate counselors.
I’ll never talk to you about anything important, and you can’t make me.
This is a shitty little office; you must be a shitty little therapist.
How long will this take?
How old are you? How are you supposed to help me if you’re still in middle school?
In our work with adolescents and young adults, we’ve directly experienced the pleasure (or pain) of being in interviews with people who want little to do with therapy, and nothing to do with us. We’ve had clients refuse to be alone in the room with us, others who refused to speak, a few who insisted on standing, and many who told us with great disdain (and punctuated with profanity) that they don’t believe in counseling.
The first part of this chapter is about interviewing clients who oppose the helping process. It’s also about the deep satisfaction of working with clients who slowly or suddenly shift their attitudes and become cooperative. When these clients eventually enter the room, begin speaking, stop swearing, agree to sit, and begin believing in counseling (and counselors!), it can be a profoundly rewarding experience.
Defining and Exploring Resistance
Freud viewed resistance as inevitable and ubiquitous. Following Freud’s lead, psychotherapists for many years considered virtually anything clients did or said as potential signs of resistance, such as
Talking too much, or talking too little
Arriving late, or arriving early
Being unprepared or overprepared for psychotherapy
The Death (or Reframing) of Resistance
Many theorists and practitioners question the nature and helpfulness of resistance as a concept. In 1984, writing from a solution-focused perspective, Steven de Shazer announced the “death of resistance.” He subsequently held a ceremony and buried it in his backyard. Other theorists and researchers—particularly from culturally diverse perspectives—have followed his lead in viewing resistance differently (Adames et al., 2022; Chimpén-López, C., 2021). They view resistance as an unhelpful linguistic creation that developed because sometimes clients don’t want to (or shouldn’t) do what their “bossy” or oppressive therapist wants them to do (Ratts et al., 2016). In other words, resistance isn’t a problem centered in the client; it’s a problem created by therapists and the power dynamic this presents.
Around the time de Shazer was burying resistance in his backyard, William R. Miller was discovering that reflective listening, empathy, and encouragement with clients who had substance problems, outperformed confrontation and behavioral interventions (W. Miller, 1978, 1983). This discovery led to the development of motivational interviewing (W. Miller & Rollnick, 1991; Miller & Moyers, 2021). Motivational interviewing (MI) is now widely acknowledged as an effective treatment for health, substance, and mental health problems (McKay, 2021; Romano & Peters, 2015).
Resistance is Multidetermined
Unlike the early psychoanalytic position, resistance is neither inevitable or ubiquitous. But it’s probably not dead either. Instead, resistance (aka ambivalence or reluctance) originates from three main sources:
Resistance from the client. Sometimes resistance is real, palpable, and originates from clients’ beliefs, attitudes, ambivalence, or internalized view of therapy as an oppressive situation (Adames et al., 2022). When resistance emanates from clients (regardless of therapist behavior), clients are usually in the precontemplation (not interested in changing) or contemplation (occasional transient thoughts of changing) stages of change (see Chapter 6 for an overview of the transtheoretical stages of change model; Prochaska & DiClemente, 2005).
Resistance that therapists stimulate. Sometimes therapists behave in ways that create resistance rather than cooperation. Overuse of confrontation or interpretation can stimulate client resistance (Romano & Peters, 2015). Therapists who don’t examine and manage their countertransference biases toward particular client populations (e.g., teenage clients, reluctant clients, mandated clients, or clients from diverse cultures), or who perpetuate marginalization of diverse populations, are especially prone to creating client resistance (Ratts, 2017; Tishby & Wiseman, 2020).
Resistance as a function of the situation. Resistance may be a product of a difficult and uncomfortable situation, a situation or expected coercive interpersonal interactions that naturally trigger reactance (i.e., negative expectations and defensiveness; Beutler et al., 2011). Reactance is a well-established psychological phenomenon (Brehm, 1966; Place & Meloy, 2018): When people feel coerced or pushed, they tend to push back, resisting the perceived source of coercion (e.g., therapist). For most mandated clients and for many ambivalent clients, resistance to therapy is a natural, situationally triggered behavior (J. Sommers-Flanagan et al., 2011). Also, for clients with diverse ethnicities or societally-marginalized identities, therapy can naturally feel like the repetition of power-imbalanced colonization experiences (Gone, 2021; Singh et al., 2020).
We realize that framing resistance as multidetermined and natural (or burying it) doesn’t automatically make it easier to handle (J. Sommers-Flanagan & Bequette, 2013). To therapists, resistance can still feel aggressive, provocative, oppositional, and threatening.
It’s unrealistic to expect all clients—especially adolescents or mandated adults in precontemplation or contemplation stages of change—to immediately speak openly and work productively with an unfamiliar authority figure. It’s also unrealistic to expect clients for whom therapy is a new and uncomfortable experience to immediately begin sharing their innermost thoughts. If you use the word resistance, it’s helpful to add the word “natural.” Doing so offers empathy for the client’s entry into an uncomfortable situation and acknowledges the need for strategies and techniques for dealing with client behaviors that are too easily labeled resistant (Hara et al., 2018; Miller & Moyers, 2021). The central question then becomes: What clinician behaviors reduce natural client resistance and defensiveness?
Motivational Interviewing and Other Strategies
In their groundbreaking text, Motivational Interviewing, W. Miller and Rollnick (1991, 2002, 2013) described a practical approach to recognizing and working with client resistance. They emphasized that most humans are ambivalent about personal change because of competing motivations. For example, a client may simultaneously have two competing motivations about smoking cigarettes:
I should quit because smoking is expensive and unhealthy.
I should keep smoking because it’s pleasurable and gives me a feeling of emotional control.
Imagine yourself in an interview situation. You recognize your client is engaging in a self-destructive behavior (e.g., smoking, cutting, punching walls). In response, you educate your client and make a case for giving up the self-destructive behavior. W. Miller and Rollnick (2002) described this classic scenario:
[The therapist] then proceeds to advise, teach, persuade, counsel or argue for this particular resolution to [the client’s] ambivalence. One does not need a doctorate in psychology to anticipate what [the client’s] response is likely to be in this situation. By virtue of ambivalence, [the client] is apt to argue the opposite, or at least point out problems and shortcomings of the proposed solution. It is natural for [the client] to do so, because [he or she] feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence. (pp. 20–21)
In MI, resistance is framed as natural ambivalence about change. Consider this from a physical perspective. If you hold out an open hand and ask someone else to do the same and then push against their hand, the other person usually pushes back, matching your force. During a clinical interview, this process happens verbally. The more you push for healthy change, the more clients push back for staying less healthy (Apodaca et al., 2015).
This leads to the central MI hypothesis for resolving client ambivalence and activating motivation:
This points toward a fundamental dynamic in the resolution of ambivalence: It is the client who should be voicing the arguments for change. (W. Miller & Rollnick, 2002, p. 22, italics added)
But how can clinicians help clients make arguments for change?
MI practitioners refer to clients voicing their own arguments for change as change talk. When clients voice their arguments against change, it’s called sustain talk,because clients are arguing to continue or sustain their unhealthy behaviors. The central hypothesis of MI is that the more clients engage in change talk, positive change is more likely to occur.
MI has relational and technical components. The relational component involves embracing a spirit of collaboration, acceptance, and empathy. Embracing the relational component is crucial, if only because clients who report greater secure attachment to their therapists, also report less resistance (Yotsidi et al., 2019). The technical components include intentional evocation and reinforcement of client change talk (W. Miller & Rose, 2009). In practice, it’s difficult to separate the relational and technical components, and it’s likely more efficacious when they’re delivered together anyway. As you work with reluctant, ambivalent, or so-called resistant clients, you’ll need to make sure your Rogerian person-centered hat is firmly in place, while simultaneously using good behavioral skills to evoke and reinforce change talk.
Using Open Questions, Opening Questions, Evocation, and Goal-Setting Strategies
Open questions are fundamental to MI. However, W. Miller and Rollnick (2013) cautioned asking too many questions, including open questions:
A simple rhythm in MI is to ask an open question and then to reflect what the person says, perhaps two reflections per question, like a waltz. Even with open questions, though, avoid asking several in a row, or you may set up the question-answer trap. (p. 63)
Miller and Rollnick (2013) recommended loosely following their two-to-one waltz metaphor; the point is to do more reflecting than questioning. They offer a stronger warning against repeated closed questions, noting, “Chaining together a series of closed questions can be deadly for engagement” (p. 63).
When opening sessions with clients who may be unenthused to see you, you should use positive, strength-focused, empathic, and non-blaming opening questions:
What brings you here today and how do you hope we might help? (Miller & Moyers, 2021, p. 95)
What would make this a helpful visit?
If we have a great meeting today, what will happen?
What needs to happen in here for our time to be productive?
Open questions and opening questions are especially good tools for evoking clients’ strengths, hope, and solutions (McKay, 2021). Not surprisingly, reluctant clients tend to be more responsive when therapists pursue strengths, rather than pathology. Evocation is a technique used to help clients speak to their resources and strengths. Miller and Moyer (2021) view evocation as inherently containing the message: “You have what you need, and together we’re going to find it (p. 93”). If you’re using open questions to bypass natural resistance, you should aim toward evoking client change talk.
Consider the following example of using a variety of questions to facilitate change talk in an emergency room setting (M. Cheng, 2007, p. 163, parenthetical comments added):
Clinician: What would make today’s … visit helpful? (Clinician asks for goals.)
Patient: I want to kill myself, just let me die… (Patient states unhealthy goal/task.)
Clinician: I’m sure you must have your reasons for feeling that way … What makes you want to hurt yourself? (Clinician searches for underlying healthy goal.)
Patient: I just can’t stand the depression anymore and all the fighting at home. I just can’t take it. (The underlying healthy goals include coping with depression and fighting.)
Clinician: … so we need to find a way to help you cope with the depression and the fighting. You told me yourself that there used to be less fighting at home. What would it be like if we found a way to reduce the fighting, have people getting along more? (Clinician uses past hope to focus on future goal)
Patient: A lot better, I guess. But it’s probably not going to happen. (Client expresses little hope)
Clinician: Okay, I can see why you’re frustrated and I do understand that probably the depression makes it hard to see hope. But I believe that there is a part of you that is stronger and more hopeful, because otherwise you wouldn’t be here talking with me. (Clinician externalizes unhealthy thoughts or behaviors as being part of the depression and tries to help the patient rally against the depression.) That hopeful part of you said that your mood used to be happy. What would it be like if we could get your mood happy again?
Patient: A lot better I guess.
Clinician: Just to help me make sure I’m getting this right then, what would you like to see different with your mood? (The clinician reinforces the client’s goals by having the client articulate them.)
Patient: I want to be happy again.
Clinician: And at home, what would you like to see with how people get along?
Patient: I want us to get along better.
Clinician: Let’s agree then that we will work together on finding a way to help people get along, as well as help your mood get better. How does that sound? (Clinician paraphrases patient’s healthy goals.)
Patient: Sounds good… (Patient agrees with goals.)
In this example, Cheng (2007) illustrated how to help patients articulate goals and potential benefits of positive change (change talk). Although the process began with a negatively worded question—“What makes you want to hurt yourself?”—Cheng listened for positive, health-oriented goals. This is an important principle: Even when exploring emotional pain, you can listen for and resonate with unfulfilled positive goals contributing to that pain.
Using Reflection, Amplified Reflection, and Undershooting
Throughout this text, we’ve emphasized nondirective interviewing skills: paraphrasing, reflection of feeling, and summarizing. Research on MI supports this emphasis, showing that these reflective techniques are powerful tools for working with resistance (McKay, 2021). W. Miller and Rollnick (2002, pp. 100–101) provided examples of simple reflections that reduce resistance:
Client 1: I’m trying! If my probation officer would just get off my back, I could focus on getting my life in order.
Therapist 1: You’re working hard on the changes you need to make. Or,
Therapist 1: It’s frustrating to have a probation officer looking over your shoulder.
Client 2: Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint!
Therapist 2: It’s hard to imagine how I could possibly understand.
Client 3: I couldn’t keep the weight off even if I lost it.
Therapist 3: You can’t see any way that would work for you. Or,
Therapist 3: You’re rather discouraged about trying again.
When therapists accurately reflect client efforts, frustration, hostility, and discouragement, the need for clients to defend their positions is reduced.
Reflections also stimulate talk about the constructive side of ambivalence. While supervising graduate students in counseling and psychology as they conducted hundreds of brief interviews with client-volunteers, we noticed that when student therapists made an inaccurate reflection, the volunteer-clients felt compelled to clarify their feelings and beliefs in ways that rebalanced their ambivalence. For example:
Client: I’m pissed at my roommate. She won’t pick up her clothes or do the dishes or anything.
Therapist: You’d like to fire her as a roommate.
Client: No. Not that. There are lots of things I like about her, but her messiness really annoys me.
This exchange shows the interviewer inadvertently overstating the client’s negative view of the roommate. In response, the client immediately clarifies: “There are lots of things I like about her.”
As it turns out, the interviewer accidentally used an MI technique called amplified reflection (W. Miller & Rollnick, 2013). Amplified reflection involves intentionally overstating the client’s main message. W. Miller and Rollnick wrote: “As a general principle, if you overstate the intensity of an expressed emotion, the person will tend to deny and minimize it, backing off from the original statement” (p. 59).
When used intentionally, amplified reflection can feel manipulative. This is why amplified reflection is used along with genuine empathy and never includes sarcasm. Instead of being a manipulative response, it’s the therapist’s effort to deeply empathize with client frustration, anger, and discouragement. The following are amplified reflections. Scenario 1 involves a mother of a child with a disability and her ambivalence over whether she can take any time for self-care:
Client 1: My child has a serious disability, so I have to be home for him.
Therapist 1: You need to be home 24/7 and turn off any needs you might have to get out and take a break.
Client 1: Actually, that’s not totally true. Sometimes, I think I need to take some breaks so I can do a better job when I’m home.
Scenario 2 involves a college student with ambivalence over giving herself the time and space to grieve her grandmother’s death.
Client 2: When my grandmother died last semester, I had to miss classes and it was a total hassle.
Therapist 2: You don’t have much of an emotional response to your grandmother’s death—other than it’s really inconveniencing you.
Client 2: Well, it’s not like I don’t miss her, too.
Amplified reflection is an empathic effort to fully resonate with one side of the client’s ambivalence; it naturally nudges clients the opposite direction.
It’s also possible to use reflection to understate what clients are saying. W. Miller and Rollnick (2013) refer to this as undershooting. They advocate using it to encourage clients to continue exploring their thoughts and feelings:
Client: I can’t stand it when my mom criticizes my friends right in front of me.
Therapist: You find that a little annoying.
Client: It’s way more than annoying. It pisses me off.
Therapist: What exactly pisses you off about your mom criticizing your friends?
Client: It’s because she doesn’t trust me and my judgment.
In this example, the therapist uses an understatement and then an open question to continue exploring what hurts about the mother’s criticism.
Coming Alongside (Using Paradox)
Intentionally undershooting or using amplified reflections are subtle ways to move client talk in particular directions. A less subtle form of this is paradox. Paradox has traditionally involved prescribing the symptom (Frankl, 1967). For example, with a client who is using alcohol excessively, a traditional paradoxical intervention would involve something like, “Maybe you’re not drinking enough.”
Paradox is a high-risk and provocative intervention. We don’t advocate using traditional paradox. Interestingly, Viktor Frankl, who wrote about paradox in the early 1900s, viewed paradox as operating based on humor. It’s as if clients unconsciously or consciously understand the silliness of behaving in a destructive extreme and consequently pull back in the other direction. Frankl’s formulation might be viewed as working with ambivalence in a manner similar to MI.
W. Miller and Rollnick (2013) discuss using paradox to address resistance, but refer to it as coming alongside. Similar to amplified reflection, coming alongside is used with empathy and respect. The difference between amplified reflection and coming alongside is that in the latter the therapist makes a statement instead of a reflection. Here are two examples:
Client 1: I don’t think this is going to work for me, either. I feel pretty hopeless.
Therapist 1: It’s certainly possible that after giving it another try, you still won’t be any better off, so it might be better not to try at all. What’s your inclination?
Client 2: That’s about it, really. I probably drink too much sometimes, and I don’t like the hangovers, but I don’t think it’s that much of a concern, really.
Therapist 2: It may just be worth it to you to keep on drinking as you have, even though it causes some problems. It’s worth the cost.
Using coming alongside requires authentic empathy for the less healthy side of the ambivalence.
W. Miller and Rollnick (2002) commented on the difference between using coming alongside as compared to traditional paradox:
We confess some serious discomfort with the ways in which therapeutic paradox has sometimes been described. There is often the sense of paradox being a clever way of duping people into doing things for their own good. In some writings on paradox, one senses almost a glee in finding innovative ways to trick people without their realizing what is happening. Such cleverness lacks the respectful and collaborative tone that we understand to be fundamental to the dialectical process of motivational interviewing. (p. 107)
Paradoxical techniques should be delivered along with basic person-centered core attitudes of congruence, unconditional positive regard, and empathic understanding. Paradox shouldn’t be used as a clever means to outwit or trick clients, but to explore the alternative outcome out loud with the client and allow them to respond.
Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback
Clients sometimes begin interviews with hostility, anger, or resentment. If clinicians handle these provocations well, clients may open up and cooperate. The key is to keep an accepting attitude and restrain from lecturing, scolding, or retaliating if clients express hostility.
Empathy, emotional validation, acceptance, and concession can elicit cooperation. We often coach graduate students to use concession when power struggles emerge, especially when working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). If a young client opens a session with “I’m not talking and you can’t make me,” conceding power and control can shift the dynamic: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s perspective and concedes an initial victory in what the client might view as a struggle for power. MI therapists refer to this as affirming the client.
Empathic, emotionally validating statements are also important. If clients express anger about you or therapy, a reflection of feeling and/or feeling validation response communicates that you hear their emotional message. In some cases, you can go beyond empathy and emotional validation and join clients with parallel emotional responses:
I don’t blame you for feeling pissed about having to see me.
I hear you saying you don’t trust me, which is totally normal. You don’t know me, and you shouldn’t trust me until you do.
It sucks to have a judge require you to meet with me.
I know we’re being forced to meet, but we’re not being forced to have a bad time together.
Radical acceptance (RA) is a principle and technique based on person-centered theory and dialectical behavior therapy (Görg et al., 2019). RA involves consciously accepting and actively welcoming all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). Here’s a case where a client began a session with angry statements about counseling:
Opening client volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.
RA return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate counseling but just sit here and pretend to cooperate. I really appreciate your telling me exactly where you’re coming from.
RA can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. One version of this is the love reframe (J. Sommers-Flanagan & Barr, 2005).
Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. Let’s just get this over with.
Therapist: You must really love your daughter to come to a meeting you think is bullshit.
Client: (softening) Yeah. I do love my daughter.
The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone. The love reframe shifts the interview to a more pleasant and cooperative focus.
Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings … pausing … and then following with honest feedback and a solution-focused question.
I hear you saying you hate the idea of talking with me. I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent.] You’re in legal trouble. I want to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour, or we can talk about how you might dig yourself out of this legal hole. I can go either way. What do you think … if we have a good meeting today, what would we accomplish?
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The chapter goes on and on from here, including content on dealing with clients who may be delusional, as well as substance abuse interviewing.
Also, if you want more info, here’s a nice article, albeit dated, where Miller and Rollnick write about 10 things that MI is NOT.
Recently, I had the honor of presenting to Camp Mak-A-Dream residents (13-20 year-olds) on “Happiness and You.” To empower the residents—all of whom have experienced brain tumors—and resonate with the challenges of being human and having emotions, I shared the Three Step Emotional Change Technique. Then, I invited a volunteer to help me demonstrate how sometimes our brains can trick us by immediately providing the wrong answer to a question. A marvelous young man named Brandon stepped up and volunteered.
Here’s the video link, as recorded by Alli Bristow, last year’s Montana School Counselor of the Year (you can hear her reactions, which are pretty fun too):
You can watch the video, but I’m also sharing a description and rationale for the activities below.
The Riddle Activity
You’ll see me asking Brandon to respond to three riddles. I manage to trick him with the first one. For the second one, he’s briefly fooled, and then catches himself and gives the right answer. On the third, he pauses and gets the right answer the first time.
Why This Activity
I’ve used riddles like these in individual counseling with youth and in group presentations (as illustrated in the video). The riddle activity is all about a basic cognitive therapy message: If we go with our automatic thoughts, without pausing and evaluating them, we can be wrong. However, if we pause to evaluate the situational context and our reactive thoughts, sometimes we can override our automatic and possibly maladaptive impulses (Aaron and Judy Beck would be proud).
The Next Lesson
In the video, you only see Brandon and me doing the riddles. He’s great. When I’m doing this presentation (or using it in counseling) after the riddles, I immediately give the youth a situational example. I say something like, “Okay. Now let’s say I go to the same high school as Brandon, and I know him, and I’m walking by him in the hall at school. When I see him, I say ‘Hi Brandon!” But he just keeps on walking. What are my first thoughts?”
Whether I’m working with a group or with individuals, the young people are usually very good at suggesting possible immediate thoughts. They say things like: “You’re probably thinking he doesn’t like you.” Or, “Maybe you think he’s mad at you.”
At some point, I ask, “Have you ever said hello to someone and have them say nothing back?” There are always head nods and affirming responses.
Way back in our “Tough Kids, Cool Counseling” book, Rita and I wrote about the typical internalizing and externalizing responses that people tend to have in reaction to a possible social rejection. The internalizing response is depressed, anxious, and self-blaming. Internalizing thoughts usually take people down the track of “What did I do wrong” or “What’s wrong with me?” Alternatively, some youth have externalizing thoughts. Externalizing thoughts push the explanation outward, onto the other person. If you’re thinking externalizing thoughts, you’re thinking, “What’s wrong with him?” or “That jerk!” or “Next time, I’m not saying hi to him.” Back in the day, Kenneth Dodge wrote about externalizing thoughts in adolescents as contributing to aggression; he labeled this cognitive error “the misattribution of hostility.”
In counseling and in group presentations, the next step is to ask for neutral and non-blaming explanations for why Brandon didn’t say hello. The youth at Camp Mak-A-Dream were quick and efficient: “He probably didn’t hear you.” “Maybe he was having a bad day.” “He could have had his earbuds in.” “Maybe he was feeling shy?”
What’s the Point?
One goal of these activities is to help young people become more reflective and thoughtful. My neuroscience enthralled friends might say I’m working their frontal lobe muscles. I basically agree that whenever we can engage teens with thoughtful and reflective processes, they may benefit.
But the other goal may be even more important. Although I want to teach young people to be thoughtful, I also want to do that in the context of an engaging, sometimes fun, and interesting relationship. For me. . . it’s not just teaching and it’s not just learning. It’s teaching and learning in the crucible of a therapeutic relationship. As one of my former teen clients once said, “That’s golden.”
I’m continuing with the theme of featuring diverse identities from the Clinical Interviewing (7th edition) textbook with a case example written by Dr. Umit Arslan. Dr. Arslan is writing about his experience as an international graduate student in counseling, when he was at the University of Montana. Currently, he’s a faculty member at the University of Nebraska-Kearney.
The photo is from when I visited him in Istanbul in January, 2023.
Enjoy!
As you’ll see below, Umit’s experience was unique. Given his Turkish heritage and cultural background, he needed to reflect and engage in a self-awareness process to experiment with finding a better way to introduce himself to clients. What I love most about this essay is Umit’s authentic description of his own experience. His answer to a better way to introduce himself won’t be the right answer for everyone. But his process is open and admirable.
CASE EXAMPLE 2.2: BEING A COUNSELOR FIRST . . . AND TURKISH SECOND, WORKED BETTER THAN BEING TURKISH FIRST . . . AND A COUNSELOR SECOND
Finding the right words and ways to introduce yourself is important. In this essay, Ümüt Arslan, Ph.D., an associate professor of counseling at İzmir Democracy University (Turkey), writes about challenges he faced as an international doctoral student in counseling at the University of Montana. Put yourself in Dr. Arslan’s shoes as he discovers (for him) a better way of introducing himself.
While pursuing my doctoral degree in the U.S., my supervisor and I discussed how to share my cultural identity and accent to clients. When I shared, my clients were not only interested in my appearance and accent, but also about my diet, coffee preferences, job, and of course, about my native country, Turkey. But they were reluctant to talk about themselves.
Clients assumed I was Muslim and against alcohol. Their assumptions were especially challenging because they were inaccurate. I was not religious, and like many Americans, I enjoyed having a beer after work. I wanted to challenge clients’ assumptions about my identity, but worried about countertransference and focusing too much on myself.
One cisgender female client came for an intake interview. She saw me, grabbed her bag (almost the size of a camping tent), and put it on her knees. I couldn’t see her face. I told her she could put the bag down if she wanted to. She declined.
When I re-watched this and other sessions, the striking thing was that my clients (mostly White) appeared stressed at the sight of me, a bearded Turkish man with dark skin. They didn’t even talk about the problems they had written on their intake form. My identity as a Turkish man overshadowed everything else. I needed a path forward.
In class, my supervisor discussed alternative ways to open sessions. I tried asking clients: “If you were the counselor today, what question would you ask yourself?” Clients suddenly engaged with me, giving deep and enthusiastic answers to their own questions. I stopped opening sessions by emphasizing cultural differences. Instead, I focused on my counselor identity, saying: “I completed my master’s degree and am currently a doctoral student. What do you think is the best question for me to ask you for us to have a good start here today?”The message, “I am here with my counselor identity” instead of “I’m a Turkish man in the U.S., and desperate to explain my culture to you,” had an amazing effect. Using a less cultural opening was more culturally sensitive. Clients could naturally introduce their own cultural identities, with fewer assumptions about me. Although I could still talk about culture, emphasizing my counselor identity enabled me to focus on counseling goals, the therapeutic relationship, and evidence-based counseling interventions.
Last week was about emotional journaling. This week, we stick with the power of words and writing and take a dive into an evidence-based therapeutic writing activity called the Best Possible Self.
You all already know about optimism and pessimism.
Some people see the glass half full. Others see the glass half empty. Still others, just drink and savor the water, without getting hung up on how much is in the glass. Obviously, there are many other responses, because some people spill the water, others find a permanent water source, and others skip the water and drink the wine or pop open a beer.
Reducing people to two personality types never works, but that doesn’t stop people from labeling themselves or others as optimists or pessimists. This week’s activity—The Best Possible Self—is an optimism activity. You don’t have to be a so-called optimist to use it. And the good news is, regardless of your labels, the Best Possible Self writing activity is supposed to crank up your sense of optimism. That’s cool, because generally speaking, optimism is a good thing. Here’s what the researchers say about the Best Possible Self (BPS) activity.
[The following is summarized from Layous, Nelson, and Lyubomirsky, 2012]. Writing about your Best Possible Self (also seen as a representation of your goals) shows long-term health benefits, increases life satisfaction, increases positive affect, increases optimism, and improves overall sense of well-being. Laura King, a professor at U of Missouri-Columbia developed the BPS activity.
King’s original BPS study involved college students writing about their Best Possible Selves for 15 minutes a day for two weeks. The process has been validated with populations other than college students. If you want to jump in that deep, go for it. On the other hand, if you want a lighter version, here’s a less committed alternative:
Spend 10 minutes a day for four consecutive days writing a narrative description of your “best possible future self.”
Pick a point in the future – write about what you’ll be doing/thinking then – and these things need to capture a vision of you being “your best” successful self or of having accomplished your life goals.
As with all these activities, monitor your reactions. Maybe you’ll love it and want to keep doing it. Maybe you won’t.
If you feel like it, you can share some of your #writing on social media.
Berkeley’s Greater Good website includes a nice summary of the BPS activity. Here’s a pdf from their website:
Being a counseling and psychotherapy theories buff, I should mention that this fantastic assignment is very similar to the Adlerian “Future Autobiography.” Adler was way ahead of everyone on everything, so I’m not surprised that he was thinking of this first. Undoubtedly, Adler saw the glass half full, sipped and savored his share, and then shared it with his community. We should all be more like Adler.
Nothing works for everyone. Not everyone is comfortable writing about their experiences and not everyone can benefit from therapeutic writing. But, for those keen on the expressive writing modality, you can get out your pen or laptop and make a little therapeutic magic.
For this week’s Montana Happiness Challenge, I phrased it this way: What if, by engaging in a simple procedure for three consecutive days, you could obtain the following benefits?
A reduced need to go see a physician
Improved immune functioning
Fewer physical ailments or symptoms
Less distress
Less negative affect
Less depression
Improved GPA
Less absenteeism from work
As it turns out, according to social psychologist and prominent researcher, James Pennebaker, there is a simple procedure for accomplishing all of the above, right at your fingertips. Literally. At. Your. Fingertips. All you have to do is write about hard, difficult, or traumatic experiences. Here’s an example (summarized) of his instructions:
For the next three days write about your very deepest thoughts and feelings about an extremely important emotional issue that has affected you and your life. When writing, really let go and explore your deepest emotions and thoughts. You might want to tie your writing into your relationships with others or to your past/present/future, or to who you’ve been, who you are, and who you’d like to be in the future. You can write about the same topic every day or a new one every day. Keep your writing confidential. Don’t worry about spelling, grammar, etc., just write for 15-30 minutes straight. (adapted from Pennebaker, 1997)
I’ve been gobsmacked (aka astounded) by Pennebaker’s research for three decades. So much so that I remember where I was when I first read his 1986 article. Despite my gob-smacked-ness, I think it’s important to remember that Pennebaker is a social psychologist; he isn’t a clinical or counseling psychologist, a clinical mental health counselor, or a clinical social worker. As a consequence, I’m not asking you to leap right into his assignment without support. In fact, most researchers, including Pennebaker, believe you can gain the same benefits by talking about painful emotional experiences with a counselor or psychotherapist. One additional caveat: Pennebaker has also found that when writing or talking about traumatic experiences, often people feel distressed or emotionally worse to start, but over time they begin feeling better than they did in the beginning.
To do this activity, just think about Pennebaker’s method and his claims, and notice: (a) what you think of his idea, (b) whether you would ever like to try his technique, and (c) if you chose to try to process some deeper emotional issues, whether you would prefer writing or talking about them.
If you decide to really try Pennebaker’s method (that’s up to you), remember that your first reaction might be to feel worse. Therefore, having someone you trust to confide in about how you’re feeling through the process might be a good idea.
For me–and I know I’m weird–I like to go back and read some of the early research on these “therapeutic techniques.” Sometimes there’s no research to be found (think: somatic approaches or polyvagal theory); other times, the gaps between what was studied and what the media and popular psychology reports is huge (think: adverse childhood experiences and the research on predicting divorce); but on occasion, the original research is stunningly good. Here’s one of Pennebaker’s early studies. It’s really worth a read:
This morning’s weekly missive of “most read” articles from the Journal of the American Medical Association included a study evaluating the effects of high-dose “fluvoxamine and time to sustained recover in outpatients with COVID-19.” My reaction to the title was puzzlement. What could be the rationale for using a serotonin specific reuptake inhibitor for treating COVID-19? I read a bit and discovered there’s an idea and observations that perhaps fluvoxamine can reduce the inflammation response and prevention development of more severe COVID-19.
To summarize, the results were no results. Despite the fact that back in the 1990s some psychiatrists and pharmaceutical companies were campaigning for putting serotonin in the water systems, in fact, serotonin doesn’t really do much. As you know from last week, serotonin-based medications are generally less effective for depression than exercise.
For the happiness challenge this week, we’re touting the effectiveness of my own version of what we should put in the water or in the schools or in families—the Three-Step Emotional Change Trick. Having been in a several month funk over a variety of issues, I find myself returning to the application of the Three-Step Emotional Change Trick in my daily life. Does it always work? Nope. Is it better than feeling like a victim to my unpleasant thoughts and feelings? Yep.
I hope you’ll try this out and follow the instructions to push the process outward by sharing and teaching the three steps. Let’s try to get it into the water system.
Active Learning Assignment 9 – The 3-Step Emotional Change Trick
Almost no one likes toxic positivity. . . which is why I want to emphasize from the start, this week’s activity is NOT toxic positivity.
Back in the 1990s I was in full-time private practice and mostly I got young client referrals. When they entered my office, nearly all the youth were in bad moods. They were unhappy, sad, anxious, angry, and usually unpleasantly irritable. Early on I realized I had to do something to help them change their moods.
An Adlerian psychologist, Harold Mosak, had researched the emotional pushbutton technique. I turned it into a simple, three-step emotional change technique to help young clients deal with their bad moods. I liked the technique so well that I did it in my office, with myself, with parents, during professional workshops, and with classrooms full of elementary, middle, and high school students. Mostly it worked. Sometimes it didn’t.
This week, your assignment is to apply the three-step emotional change trick to yourself and your life. Here’s how it goes.
Introduction
Bad moods are normal. I would ask young clients, “Have you ever been in a bad mood?” All the kids nodded, flipped me off, or said things like, “No duh.”
Then I’d ask, “Have you ever had somebody tell you to cheer up?” Everyone said, “Yes!” and told me how much they hated being told to cheer up. I would agree and commiserate with them on how ridiculous it was for anyone to ever think that saying “Cheer up” would do anything but piss the person off even more. I’d say, “I’ll never tell you to cheer up.* If you’re in a bad mood, I figure you’ve got a good reason to be in a bad mood, and so I’ll just respect your mood.” [*Note to Therapists: This might be the single-most important therapeutic statement in this whole process.]
Then I’d ask. “Have you ever been stuck in a bad mood and have it last longer than you wanted it to?”
Nearly always there was a head nod; I’d join in and admit to the same. “Damn those bad moods. Sometimes they last and last and hang around way longer than they need to. How about I teach you this thing I call the three-step emotional change trick. It’s a way to change your mood, but only when YOU want to change your mood. You get to be the captain of your own emotional ship.”
Emotions are universally challenging. I think that’s why I never had a client refuse to let me teach the three-steps. And that’s why I’m sharing it with you now.
Step one is to feel the feeling. Feelings come around for a reason. We need to notice them, feel them, and contemplate their meaning. The big questions here are: How can you honor and feel your feelings? What can you do to respect your own feelings and listen to the underlying message? I’ve heard many answers. Here are a few. But you can generate your own list.
Frowning or crying if you feel sad
Grimacing and making angry faces into a mirror if you feel angry
Drawing an angry picture
Punching or kicking a pillow (no real violence though)
Going outside and yelling (or screaming into a pillow)
Scribbling on a note pad
Writing a nasty note to someone (but not delivering it)
Using your words, and talking to someone about what you’re feeling
Step two is to think a new thought or do something different. This step is all about intentionally doing or thinking something that might change or improve you mood. The big question here is: What can you think or do that will put you in a better mood?
I discovered that kids and adults have amazing mood-changing strategies. Here’s a sampling:
Tell a funny story (“Yesterday in math, my friend Todd farted”)
Tell a joke (What do you call it when 100 rabbits standing in a row all take one step backwards? A receding hare-line).
Tell a better joke (Why did the ant crawl up the elephant’s leg for the second time? It got pissed off the first time.)
Exercise!
Smile into a mirror
Talk to someone you trust
Put a cat (or a chicken or a duck) on your head
Chew a big wad of gum
I’m sure you get the idea. You know best what might put you in a good mood. When you’re ready, but not before, use your own self-knowledge to move into a better mood.
Step three is to spread the good mood. Moods are contagious. I’d say things like this to my clients:
“Emotions are contagious. Do you know what contagious means? It means you can catch emotions from being around other people who are in bad moods or good moods. Like when you got here. I noticed your mom was in a bad mood too. It made me wonder, did you catch the bad mood from her or did she catch it from you? Anyway, now you seem to be in a better mood. I’m wondering. Do you think you can make your mom “catch” your good mood?”
How do you share good moods? Saying “Cheer up” is off-limits. Here’s a short list of what I’ve heard from kids and adults.
Do someone a favor
Smile
Hold the door for a stranger
Offer a real or virtual hug
Listen to someone
Tell someone, “I love you”
Step four might be the best and most important step in the three-step emotional change trick. With kids, when I move on to step four, they always interrupt:
“Wait. You said there were only three steps!”
“Yes. That’s true. But because emotions are complicated and surprising, the three-step emotional change trick has four steps. The fourth step is for you to teach someone else the three steps.”
I’ll be online in about 75 minutes to present a workshop for the TexChip folks from TAMU-CC. The title of the workshop is: “Tough Kids, Cool Counseling: Strategies for Engaging and Influencing Youth.”
Here’s the link to the workshop . . . where the CEUs are free!:
You may be aware of the irony in the workshop title. . . which is the fact that very soon into the workshop I tell everyone that we should never even “think” the words “Tough kids.” The reason we drop the terminology “Tough kids” is because it blames and labels the young people with whom we’re working, and they may sense that. Instead, all we have are “Kids in tough situations” and one of the tough situations is being in counseling or therapy.
Whether I’ll see you in 75 minutes or not, here are the ppts:
As a part of a virtual symposium offered by Texas A&M University – Corpus Christi, this coming Saturday, August 26, I’m doing a 2-hour free continuing education workshop from 12-2pm Mountain time (2pm-4pm Eastern). The cool thing is that the CEUs for this workshop are FREE. The less cool thing is that the workshop is on a Saturday.
My talk is: Tough Kids, Cool Counseling: Strategies for Engaging and Influencing Youth. Even better, I’ll be preceded by Dr. Russ Curtis and Dr. Katie Goetz (9am-11am Mountain time), who are presenting a 2-hour workshop on The Mindset and Clinical Skills Needed to Thrive in Integrated Care. . . and that’s 2 more FREE CEUs.
Below, I’ve pasted the blurbs and Zoom information for these online workshops.
You are invited to join Tex-Chip Virtual Symposium on Saturday, August 26, 2023, at 10am – 3pm (CST).
Dr. Russ Curtis & Dr. Katie Goetz is scheduled to present from 10am – 12pm CST on “The Mindset and Clinical Skills Needed to Thrive in Integrated Care.” In this interactive presentation, participants will learn how to integrate clinical skills with enlightening philosophical premises to expand their understanding of providing inclusive whole-person care. Attendees will develop their clinical voice through lecture, case examples, and discussions to begin asking the right questions about how to provide next-generation integrated care.
Dr. Sommers-Flanagan is scheduled to present from 1pm – 3pm CST on “Tough Kids, Cool Counseling: Strategies for Engaging and Influencing Youth.” Engaging “tough kids” in behavioral health can be immensely frustrating or splendidly gratifying. The truth of this statement is so obvious that the supportive reference, at least according to many teenagers is “Duh!” In this 2-hour workshop, participants will learn, experience, and practice several strategies for engaging and influencing youth. Several cognitive, emotional, and constructive brief counseling techniques will be described and demonstrated. Examples include acknowledging reality, positive questioning, wishes and goals, the affect bridge, the three-step emotional change trick, what’s good about you?/asset flooding, and more. Essential counseling principles, countertransference, and cultural issues will be included.
John Sommers-Flanagan 