Hello from beautiful Albuquerque, NM where I just landed and am patiently awaiting the availability of my hotel room so I can begin taking a substantial nap.
I was looking for fellow conference attendees on my flight from Denver to Albuquerque and, of course, found them. Given that my faith in humanity is teetering on the brink right now, it was so cool (and reassuring) to meet fellow counselor educators and feel their vibes–vibes that distinctly vibrate to the frequency of big motivation to help others lead happy, meaningful, and healthy lives. Thanks, Sharon, for initiating a conversation using your extraversion skills!
This is a small conference populated with people who have big and empathic hearts. Let’s savor that for a moment.
Speaking of savoring, I have two presentations tomorrow. The first is with Dr. Ümüt Arslan of the University of Nebraska–Kearney. Dr. Arslan is a former doc student at UM, who used to refer to himself as “the only male feminist in Turkey.” He is a magnificent person and counselor and professor and I am honored to co-present with him. Our ppts:
Tomorrow afternoon, I’m flying solo and offering a presentation titled: “The Future of Counseling is Counseling for Happiness.” To save on paper, I’m posting the ppts here:
I hope we can all grow our hearts so they metaphorically become as large as the hot air balloons floating around Albuquerque this weekend, but may they be full of empathy instead of hot air.
The chapter linked below is from the book, Tough Kids, Cool Counseling: User-Friendly Strategies for Working with Challenging Youth. The book was published in 2007, so the language is outdated and some ways we talk about youth have changed. For example, we’re no longer comfortable with the term “Tough Kids” because referring to youth as “tough” centers the problem in them, which isn’t fair and can make change more difficult. We have a different philosophy now (please excuse the language as I make my point):
In the beginning, we thought our “tough kids” book title was clever. Sometimes Rita and I argued about who came up with our ingeniously clever title. But now we’re uncomfortable with message embedded in the title. We believe we were wrong to label youth as “tough.” There are no tough kids. There are only kids in tough situations. And one, among many tough situations young people face, is counseling. When they roll their eyes, tell us to fuck off, or refuse to talk, we shouldn’t blame them; we shouldn’t call them difficult, disturbed, or tough. Blaming young people for behaving in ways that appear defensive, obnoxious, or resistant contributes to the problem. Too often we make the mistake of thinking we’re special (we’re not) and that young people should automatically respect us (they won’t) or that they should bow to the alter of our guidance (which is as flawed as we are). Working with youth requires humility, acceptance, creativity, and compassion. We should seek to communicate to all young people who enter our space that there is no other place we’d rather be than in the room with them—without ever directly saying that there is no other place we’d rather be than in the room with them. We call that radical interest. But we’re not talking about radical interest in helping or radical interest in being competent or radical interest in social justice (all of which are great things). We’re talking about radical interest in another living, breathing, person who in this present moment, is experiencing a challenging life, part of which involves being in the room with a fucking counselor.
Not long ago, a friend called me and wanted to read me a quote from the book, “My Friends” by Fredrik Backman. He said the quote made him think of me. He read it. I loved it.
Louisa is a teenager, the best kind of human. The evidence for this is very simple: little children think teenagers are the best humans, and teenagers think teenagers are the best humans, the only people who don’t think that teenagers are the best humans are adults. Which is obviously because adults are the worst kind of humans (p. 1).
I’m honored my friend thought of me when he read this passage. I wish all teens could automatically sense that I think they’re the best humans. But unfortunately, adults are so often so dismissive and demeaning of teenagers that teenagers typically assume the opposite is true. That translates into the sad fact that if we’re going to convince teenagers we think they’re the best humans, we must do the direct and indirect work, which is not easy because we’ve been so effective—as individuals and as a society—to make teenagers think they’re the worst humans.
Here’s a link to the chapter. I hope it helps you convince teenagers they’re the best humans.
As a senior in high school, I had a chance to say a few words at the annual football awards banquet. Apparently, my stammering and stuttering through two whole minutes were so inspiring that afterward, an assistant coach took me aside and offered seven words of feedback, “You need to take a speech class.”
His words sunk in. I was a terrible and inarticulate speaker. But did I take his advice? Nope. I was too scared to even try to get better at public speaking.
Fast forward 51 years. Now I speak all the time. In one of my most recent speaking gigs, David Shepard and Erica Liebman had me on their very cool podcast called, “Therapy with Men and Boys.”
On the podcast, we talked about men and boys and therapy and suicide. We talked so much they made my appearance into two episodes. And David, whose work I respect a ton, told me, “Your comfort in front of a mic is really impressive. I can imagine how much your students liked your classes in your teaching days.”
Thanks David! What a difference 51 years makes.
I share this story because things change with time. . .and I’m hoping (in the sociocultural-political realms) that time will change some things (for the better).
If you’re interested in therapy in general and therapy with men and boys in particular, I’m sharing links to part 1 and 2 of the podcast; they’re about 35 minutes each.
Tammy, Dylan, and I are on our way to Polson, MT this morning to provide a 6-hour workshop on Counseling Youth.
The workshop title, “Tough Kids, Cool Counseling,” is a remnant of days gone by. Back in 1996, as Rita and I were driving from Missoula to Absarokee, we came up with that title, which we published as a book in 1997. The second edition came out in 2007.
For many years, we argued about who came up with what we considered a very nice title. I thought it was my idea. Rita thought it was hers. We were both equally shocked at each others’ claims. Have you ever had that experience with a romantic partner?
But, a few years after publishing the second edition, I gave up all claims to the title, because I suddenly realized that the title was neither nice nor cool. Constructing youth problems as “in them” was not good and not right. The title labeled the youth as “tough,” in essence, blaming them for their problems.
For the past two decades, I’ve seen youth problems differently. Now, I avoid using the phrase “Tough kids.” Instead, I advocate for framing the issues as “kids in tough life and personal situations.” I’ve decided that going to counseling is just another tough situation that many youth are forced into.
So why am I still using this title? I use it because I like to make the point–after using the phrase Tough Kids for the first five minutes–that I’ve stopped using it and that I won’t use it for the rest of the presentation and that we should all give it up together, and not even THINK about tough kids.
With that fun anecdote out of the way, I’m looking forward to a fun day of mutual learning with therapists who work for the Confederated Salish & Kootenai Tribes. And. . .here’s a pdf of the very long powerpoint slide deck.
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?
*********************
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.
The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about.
