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What You Should Know About Motivational Interviewing (and more)

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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:

  1. 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).
  2. 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).
  3. 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.  

Miller & Rollnick 2009 What MI is NOTDownload
Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, culture, diversity, Happiness, Suicide Assessment and Intervention

Coming Soon: Maryland’s 36th Annual Suicide Prevention Conference

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Why Do We Need a Strengths-Based Approach to Suicide Assessment and Treatment?

Imagine this: You’re living in a world that seems like it would just as soon forget you exist. Maybe your skin color is different than the dominant people who hold power. Maybe you have a disability. Whatever the case, the message you hear from the culture is that you’re not important and not worthy. You feel oppressed, marginalized, unsupported, and as if much of society would just as soon have you become invisible or go away.

In response, you intermittently feel depressed and suicidal. Then, when you enter the office of a health or mental health professional, the professional asks you about depression and suicide. Even if the professional is well-intended, judgment leaks through. If you admit to feeling depressed and having suicidal thoughts, you’ll get a diagnosis that implies you’re to blame for having depressing and suicidal thoughts.  

The medical model overfocuses on trying to determine: “Are you suicidal?” The medical model is also based on the assumption that the presence of suicidality indicates there’s something seriously wrong with you. But if we’re working with someone who has been or is currently being marginalized, a rational response from the patient might be:

“As it turns out, I’ve internalized systemic and intergenerational racism, sexism, ableism, and other dehumanizing messages from society. I’ve been devalued for so long and so often that now, I’ve internalized societal messages: I devalue myself and wonder if life is worth living. And now, you’re blaming me with a label that implies I’m the problem!”

No wonder most people who are feeling suicidal don’t bother telling their health professionals.

When I think of this preceding scenario, I want to add profanity into my response, so I can adequately convey that it’s completely unjust to BLAME patients for absorbing repeated negative messages about people who look like or sound like or act like them. WTH else do you think should happen?

This is why we need to integrate strengths-based principles into traditional suicide assessment and prevention models. Of course, we shouldn’t use strengths-based ideas in ways that are toxically positive. We ALWAYS need to start by coming alongside and feeling with our patients and clients. As it turns out, if we do a good job of coming alongside patients/clients who are in emotional pain, natural opportunities for focus on strengths and resources, including cultural, racial, sexual, and other identities that give the person meaning.

I’m reminded of an interview I did with an Alaskan Native person from the Yupik tribe. She talked at length about her depression, about feeling like a zombie, and past and current suicidal thoughts. Eventually, I inquired: “What’s happening when you’re not having thoughts about suicide?” She seemed surprised. Then she said, “I’d be singing or writing poetry.” I instantly had a sense that expressing herself held meaning for her. In particular, her singing Native songs and contemporary pop songs became important in our collaborative efforts to build her a safety plan.

This coming Wednesday morning I have the honor of presenting as the keynote speaker for the Maryland Department of Health 36th Annual Suicide Prevention Conference. During this keynote, I’ll share more ideas about why a strengths-based model is a good fit when working with diverse clients who are experiencing suicidal thoughts and impulses.

With all that said, here’s the title and abstract of my upcoming presentation.

Strengths-Based Assessment, Treatment, and Prevention with Diverse Populations

Traditional suicide assessment tends to be a top-down information-gathering process wherein healthcare or prevention professionals use questionnaires and clinical interviews to determine patient or client suicide risk. This approach may not be the best fit for people from populations with historical trauma, or for people who continue to experience oppression or marginalization. In this presentation, John Sommers-Flanagan will review principles of a strengths-based approach to suicide prevention, assessment, and treatment. He will also discuss how to be more sensitive, empowering, collaborative, and how to leverage cultural strengths when working with people who are potentially suicidal. You will learn at least three practical strengths-based strategies for initiating conversations about suicide, conducting culturally-sensitive assessments, and implementing suicide interventions—that you can immediately use in your prevention work.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Happiness and Suicide at the Mental Health Academy Summit

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Good Morning or Good Afternoon (wherever you may be),

In 28 minutes I’ll be online presenting for the Mental Health Academy Suicide Prevention Summit. A big thanks to Pedro and Greg for their organizing and broadcasting of this worldwide event. I’m honored to be a part of it.

It’s still not too late to register. The link is here: https://www.mentalhealthacademy.net/suicideprevention. It’s all free . . . or you can pay a whopping $10 and have access to all the recordings. TBH, I’m not sure if I’d pay $10 to hear me (jokes), but tomorrow morning features Craig Bryan, and I’ll be an early-riser to catch him live (and free). There are also some other FABULOUS presenters.

Here are my ppts . . . just so you all have them.

Suicide MHA 8.24.2024Download

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Happiness, Therapy with Adolescents, Tough Kids Cool Counseling, Writing

Riddles, Automatic Thoughts, Thinking Errors, Misattribution . . . and a Video Demonstration

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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.”

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Hello from the Montana Conference on Suicide Prevention in Billings, Montana

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When I wrote this, I was listening to Dr. Jennifer Crumlish, a consultant for the CAMS-Care program. Dr. Crumlish provided a fantastic overview of the challenges associated with suicide prevention and interventions, along with introductory information pertaining to implementing the CAMS model. For more on CAMS-Care, see this link: https://cams-care.com/

Earlier in the day, Leah Finch—one of our excellent doc students in counseling—and I, did our presentation. Our participants were awesome. A bit later, I got to be on an “expert panel” along with several very cool people, facilitated by Dr. Jen Preble. We fielded an array of interesting questions from the audience. Very fun.

For those of you interested, here are the ppts Leah and I developed, here they are:

Suicide and Happiness COSP 2024 REVDownload
Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Multicultural

Professional Identity Among Diverse Counselors and Psychotherapists: One Perspective

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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.

[End of Case Example 2.2]

Counseling and Psychotherapy Theory and Practice, Happiness

A Conversation on CBT and Happiness with Kyrie Russ

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The Practical Psychology Podcast just dropped a new episode titled “On Happiness and a Life with Meaning.” This episode includes Kyrie Russ (the show’s host” and me in conversation about happiness, CBT, life, and other things. This conversation was based, in part, on content from a keynote I gave at a conference in Helena about 2 years ago. The ppts (which is are a bit cryptic. . .) are here:

CBT Helena Keynote 2022Download

The link to Kyrie’s excellent podcast website is below:

https://practicalpsychpod.substack.com/p/on-happiness-and-a-life-of-meaning

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Writing

The Client as Expert . . . Or Not

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While doing supervision today, I found myself encouraging my supervisee to be more direct, to embrace his knowledge and his good judgment, and to share his knowledge and judgment with his client. This is an interesting (and perhaps surprising) stance for me to take, because, as some of you know very well, I lean hard toward Rogerian theory. I’m a fan of honoring clients’ expertise and of Carl Rogers’s words that it is “the client who knows what hurts and where to go.”
As I age (more like fine wine, and not like moldy bananas, I hope), one truth I keep feeling is that nearly everything is both-and—not either-or. Yes, I believe deeply in the naturally therapeutic process of person-centered theory and therapy; providing clients with that “certain type of environment” will facilitate self-discovery and personal growth. On the other hand, sometimes clients need guidance. In my supervision case earlier today, my point was that the client was a very long way away from deeper personal insights. That meant my supervisee needed to loan the client his good judgment and decision-making skills. As you may recognize, “loaning clients our healthy egos” is psychoanalytic language. Nevertheless, the guidance I offered my supervisee was to engage in some CBT coaching
All this reminded me of a section I updated in the 7th edition of Clinical Interviewing. The section is titled, “Client as Expert” and I’ve excerpted it below. It captures the essence of honoring client wisdom, which, IMHO, should always precede more directive interventions.

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Client as Expert

Clients are the best experts on themselves and their experiences. This is so obvious that it seems odd to mention, but sometimes therapists can get wrapped up in their expertness and usurp the client’s personal authority. Although idiosyncratic and sometimes factually inaccurate, clients’ stories and explanations about themselves and their lives are internally valid and should be respected.

CASE EXAMPLE 1.1: GOOD INTENTIONS

In one case, I (John) became preoccupied about convincing a 19-year-old client—who had been diagnosed years ago with bipolar disorder—that she wasn’t really “bipolar” anymore. Despite my good intentions (I thought the young woman would be better off without a bipolar label), there was something important for her about holding on to a bipolar identity. As a “psychological expert,” I believed it obscured her many strengths with a label that diminished her personhood. Therefore, I encouraged her to change her belief system. I told her that she didn’t meet the diagnostic criteria for bipolar disorder, but I was unsuccessful in convincing her to give up the label.

What’s clear about this case is that, although I was the diagnostic authority in the room, I couldn’t change the client’s viewpoint. She wanted to keep calling herself bipolar. Maybe that was a good thing for her. Maybe that label offered her solace? Perhaps she felt comfort in a label that helped her explain her behavior to herself. Perhaps she never will let go of the bipolar label. Perhaps I’m the one who needed to accept that as a helpful outcome.

[End of Case Example 1.1]

In recent years, practitioners from many theoretical perspectives have become outspoken about the need for expert therapists to take a backseat to their clients’ lived experiences. Whether you’re working online or face-to-face, several evidence-based approaches emphasize respect for the clients’ perspective and collaboration (David et al., 2022). These include progress monitoring, client-informed outcomes, and therapeutic assessment (Martin, 2020; Meier, 2015).

When your expert opinion conflicts with your client’s perspective, it’s good practice to defer to your client, at least initially. Over time, you’ll need your client’s expertise in the room as much as your own. If clients are unwilling to share their expertise and experiences, you’ll lose some of your potency as a helper.

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So, what’s today’s big takeaway? We start with and maintain great respect for the client’s expertise. . . and then we either stay more person-centered (or psychoanalytic) or collaboratively shift toward providing more direction and guidance. And the big question is: How do we determine whether to stay less directive or become more directive?
If you feel so inclined, let me know your thoughts on that big question.
Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Group counseling, Group therapy

The Power of Language

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Language is powerful, but sometimes subtle in its influence. Last week in Group class I talked about using psychoeducation to teach people the power of language. As an example, I mentioned the work of Isolina Ricci, and the best post-divorce book ever, Mom’s House, Dad’s House. Ricci tells separated or divorced parents they should change the words they use to refer to their “Ex.” Because “Ex” refers to the former relationship with a romantic partner, it gets to the heart of how people use language to live in the past. Ricci says that we should use “My children’s Mom” or “My child’s Dad” because doing so accurately describes the current relationships. Years ago, I taught her language-based principles in the divorce education courses offered through Families First.

In a class-based group, my students brought up that perhaps we should shift from language that identifies others as “racist” to describing them as “people with racist tendencies.” I was happy my students were grappling with the influence of language. . . and was reminded of my first encounter when I really learned about the power of language and labels.

While in the University of Montana library about 4 decades ago, I recall reading something by Gordon Allport. Given it was so long ago, the memory is surprisingly vivid. Sadly, I can’t conjure up the reference. What I recall is Allport describing something like this:

First, we say, John behaves nervously.

Later, it becomes, John is nervous or anxious.

Eventually, we diagnose John: John has an anxiety disorder.

Then, we diagnose everyone similar to John, and put the disorder first: Anxiety disordered youth, like John, are more likely to. . .

In the end, we’ve inserted a trait-problem in John, without consideration of the context of his initial anxiety or the specific rate of anxiety associated with his so-called “anxiety disorder.” And then we repeat this description until the problem is fully placed inside John (and others) and rarely question that presumption.

This process begs many questions. Is the anxiety really located inside John, as if it were a personality trait or a mental disorder? Where did John’s anxiety originate? If John lived years in a frightening setting, should he be blamed and labeled for having anxiety symptoms? Might it be normal for John to expect that something bad is likely to happen?

The tendency for external observers to see behaviors or symptoms in others, and then insert the behaviors and symptoms inside of those they observe is so ubiquitous that in social/cognitive psychology, they named it the “Fundamental Attribution Error.” But even that language isn’t quite right.

Fundamental attribution error is the tendency to attribute the behaviors of others as representing a “trait” or underlying disposition in them (e.g., racist). Not surprisingly, at the same time, people also tend to attribute their own behaviors to situational factors (e.g., I was more judgmental than usual, because I was a bad mood and hadn’t slept well). To use language more precisely, the fundamental attribution error might be better described as a “common” phenomenon, instead of fundamental. And, of course, that tendency is not always in error. Maybe the better terminology would be “Common misattribution tendency.” Put more simply: We tend to blame others’ behavior on them. How common is that? Very common.

This is all very heady stuff, as is often the case when we dive into constructive language and narrative therapy principles. It tends to be easier for people to change and to believe in the possibility of people changing when we use person-first language and say things like, “engaged in racist behaviors” or “exhibited signs of anxiety,” instead of using firmly constructed attributions.  

Lately, in this blog I’ve been riffing with excerpts from our Clinical Interviewing textbook. Below, I’ve inserted another section from Clinical Interviewing. This excerpt is about using bias-free language in psychological reports.

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Using Bias-Free Language

No matter how careful and sensitive writers try to be, it’s still possible to offend someone. Writing with sensitivity and compassion toward all potential readers is difficult, but mandatory.

The publication manual of the American Psychological Association (APA, 2020, chapter 5) provides guidance regarding bias-free language. Additional details are provided in the APA’s Inclusive Language Guidelines (https://www.apa.org/about/apa/equity-diversity-inclusion/language-guidelines?_ga=2.54630952.2057453815.1669179921-716730077.1592238042).

Avoiding bias and demeaning attitudes is mostly straightforward. In addition to following the APA’s guidance and writing for a multidimensional audience, the best advice we have is to encourage you to conceptualize and write your intake report transparently and collaboratively. This means:

  1. At the beginning and toward the end of your session, speak directly with your client about the content you plan to include in the report.
  2. Rather than surprising clients with a diagnosis, be explicit about your recommended diagnosis and rationale.
  3. Discuss your treatment plan openly with clients. Doing so serves the dual purpose of providing clients with advance information and getting them invested in treatment.
  4. If you’re not clear about how your client would like to be addressed in the report (Mr., Ms., gender identity, ethnicity, etc.), ask directly. Avoid mis-labeling or mis-gendering clients in a psychological report. If you’re working with clients who have physical disabilities, check to see if person-first or disability-first language is preferred.

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I’ve been trying to keep the word-length of these blogs reasonable, and so if you’re interested in a bit more on this topic, this link will give you Practice and Reflection 8.4: “Person-First or Identity-First Language” from, of course, the Clinical Interviewing text.

person-first-or-identify-first-languageDownload
Counseling and Psychotherapy Theory and Practice, Happiness, Personal Reflections

Negative and Positive Reflections on Positive Psychology

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In my Group Counseling class, I’ve experienced predictable questioning of or resistance to evidence-based happiness ideas from positive psychology. . . and so I wrote out some of my thoughts . . . which went on and on and ended with a video clip.

Hello Group Class,

I’m writing my group takeaway to your all this week. Feel free to read at your leisure . . . or not at all . . . because I’m a writer and obviously, sometimes I get carried away and write too much.

When I responded to a question last week expressing reservations about the use of positive psychology—perhaps generally and perhaps more specifically with oppressed populations—I launched into a psychoeducational lecture. Upon reflection, I wish I had been more receptive to the concerns and encouraged the class as a group chew on the pros and cons of positive psychology in general and positive psychology with oppressed populations, in particular. I suspect this would have been an excellent discussion.

Given that we have limited time for discussion in class, I’ll share more reflections on this topic here.

1.       The concerns that were expressed (and others have expressed in your takeaways) are absolutely legitimate. I’m glad you all spoke up. Some people have used positive psychology as a bludgeon (claiming things like “happiness is a choice”) in ways that make people feel worse about themselves. Never do that!

2.       Positive psychology is poorly named (even the great positive psych researcher, Sonja Lyubomirsky, hates the name). Among its many naming problems, the word positive implies that it’s better, preferable, and the opposite of negative—which must then be the correct descriptor for all other psychology. None of this is true; positive psychology is not “better” and, in fact, it’s not even exclusively positive.

3.       The point of positive psychology is not to “take over” psychology, but to balance our focus from being nearly always on psychopathology, to being equally about strengths, joy, happiness, etc., and psychopathology. If you think of it as an effort to balance how we work with individuals, it makes more sense. The point isn’t, and never has been, that we should only focus on positive mental health regardless of how our clients and students are feeling. That would be silly and insensitive.

4.       As someone reminded me in the takeaways, the sort of happiness we focus on in positive psych is called eudaimonic happiness. This term comes from Aristotle. It refers to a longer form of happiness that emphasizes meaning, interpersonal connection, and finding the sweet spot where our own virtues intersect with the needs of the community. The other side of happiness is referred to as “hedonic” happiness. Hedonic happiness is more about hedonism, which involves immediate pleasure and material acquisitions. Nearly everyone in positive psychology advocates primarily for eudaimonic happiness, but also recognizes that we all usually need some pleasure as well.

5.       Individuals and groups who have been historically (and currently) oppressed are naturally sensitive to coercion, judgment, and possibility of repeated oppression. What this means for counselors (among many things) is that we need to careful, sensitive, and responsive to their needs and not our assumptions of their needs. They may appreciate us being positive and supportive. Or they may appreciate us explicitly acknowledging their pain and affirming the legitimacy of the reasons for their pain. There’s substantial research indicating that certain ethnic group expect counselors to be experts and offer guidance. If that’s the case, should we avoid offering guidance because a particular theorist (or supervisor) said not to offer guidance? I think not. Many clients benefit from going deep and processing their disturbing emotions and sensations. There are probably just as many who don’t really want to go deep and would prefer a surface-focused problem-solving approach. Either way, my point is that we respond to them, rather than forcing them to try to benefit from a narrow approach we learned in grad school.

6.       Good counselors . . . and you will all become good counselors . . . can use virtually any approach to make connection, begin collaborating, remain sensitive to what clients and students are saying (verbally and non-verbally), and work constructively with them on their emotions, thoughts, sensations/somatics, behaviors, and the current and/or historical conditions contributing to their distress.

7.       We should not blame clients for their symptoms or distress, because often their symptoms and distress are a product of an oppressive, traumatic, or invalidating environment. This is why reflections of feeling can fall flat or be resisted. Feeling reflections are tools for having clients sit with and own their feelings. While that can be incredibly important, if you do a feeling reflection and you don’t have rapport or a rationale, feeling reflections will often create defensiveness. Instead, it can be important to do what the narrative and behavioral folks do, and externalize the problem. When it comes to issues like historical trauma, often clients or students have internalized negative messages from a historically oppressive society, and so it makes perfect sense to NOT contribute to their further internalization of limits, judgments, discrimination, and trauma that has already unjustly taken hold in their psyche. The problem is often not in the person.     

8.       I know I said this in class, but it bears repeating that many people practice simple, superficial, and educational positive psychology using bludgeon-like strategies. Obviously, I’m not in support of that. That said, many people practice simplistic implementation of technical interventions in counseling (think: syncretism from theories class), and many counselors do bad CBT, bad ACT, bad DBT, bad behaviorism, bad existentialist therapy, and bad versions of every form of counseling out there. No matter which approach you embrace, you should do so using your excellent fundamental listening skills . . . so that if your client or student doesn’t like or isn’t benefiting from your approach, you can change it!

I want to end this little 1K word writing project with a video. In the linked clip, I’m doing about a 3 1/2 minute opening demonstrating a “Strengths-based approach” to suicide assessment and treatment planning with a 15-year-old. As you watch, ask yourself, “Is this strengths-based?” Can you identify anything that makes this approach strengths-based or as including even a whiff of positive psychology. [Again, you’re not required to watch this, I’m just rambling.]

Okay. That’s all for this Sunday evening!

John