My wife (Rita) and I used to argue over who came up with the catchy “Tough Kids, Cool Counseling” title for our 1997/2007 book with the American Counseling Association. I would swear it was MY grand idea; she would swear back that it was HER idea. If any of you are in–or have been in–romantic partnerships, perhaps you can relate to disagreements over who has all the best ideas. I doubt that this dynamic is unique to Rita and me.
Years passed . . . and now I’ve come to very much dislike the title. . . leading me to give Rita ALL THE CREDIT! You’ve got it Rita! It was all you!
Despite my dislike for the title, I still sometimes use it for workshops. Why might that be, you may be wondering? Good question. I use it so I can make the point, early in the workshop, that we should NEVER use language that blames young people for their problems or their problem behaviors. In fact, we should never even “think” thoughts that assign blame to them for being “tough.”
My reasoning for this is informed by constructive theory and narrative therapy. When we assign blame and responsibility to young people for being “tough” or “difficult” or “challenging,” we risk contributing to them holding a tough, difficult, or challenging identity–which is exactly the opposite of what we want to be doing. Instead, I tell my workshop participants that we should recognize, there are no “tough kids” . . . there are only kids in tough situations . . . and being in counseling or psychotherapy is just another tough situation that young people have to face. Consequently, it’s NOT their fault if they engage in so-called tough or challenging behaviors.
All this leads me to share that I’ll be online all day on December 6, 2024, doing a workshop for mental health professionals. The workshop, anachronistically titled, “Tough Kids, Cool Counseling” is sponsored by the Vermont Psychological Association. You can register for the workshop here: https://twinstates.ce21.com/item/tough-kids-cool-counseling-131540
Even if I do say so myself, I’m proclaiming here and now that this will be a very engaging online workshop. If you work with youth (ages 10-18) in counseling or psychotherapy, and you need/want some year-ending CEUs, we’ll be having some virtual fun on December 6, and I hope you can join in.
During my supervision this week, I noticed that the concepts and process of Motivational Interviewing came up several times. When students or professionals don’t know the basics of Motivational Interviewing (MI), I feel compelled to speak up. MI is a method, strategy, or philosophy that’s complex, nuanced, and essential. We should all know about and have MI skills. To feel the centrality of MI to counseling and psychotherapy, it helps to start with MI’s most fundamental organizing principle.
“It is the client who should be voicing the arguments for change” (Miller & Rollnick, 2002, p. 22).
If you contemplate this principle (and you should), then you’ll need to examine your own role in the change process. That’s because, if look at (or listen to) yourself, and YOU’RE the one voicing the arguments for change, you must stop.
If you don’t stop, then you may be contributing to your clients’ resistance to change.
MI ideas are challenging to our natural impulses. We want to tell clients how to be healthier, but our job is not to voice the argument for positive and healthy change; our job is to nurture their argument for positive and healthy change. This is where the nuance comes in. How can we, as interviewers (aka counselors or psychotherapists) create an interaction wherein the client is more likely to take the lead in voicing the arguments for positive and healthy change?
The answer to that question is complex, as it should be. In part, my answer today is to include an excerpt from Chapter 12 (Challenging Client Behaviors and Demanding Situations) of our Clinical Interviewing text. This excerpt starts with the topic of “Challenging Client Behaviors” or behaviors that clients engage in that counselors and psychotherapists often find challenging. The content includes a discussion of the concept of “resistance,” MI strategies, as well other ideas of our own and from the literature.
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Challenging Client Behaviors
As the client and therapist talk more and more about the solution they want to construct together, they come to believe in the truth or reality of what they are talking about. This is the way language works, naturally.
—Insoo Kim Berg and Steven de Shazer, Making numbers talk, 1993, p. 6
Not all clients are equally cooperative. Here are a few opening lines we’ve heard over the years:
Do I have to be here?
No disrespect, but I hate counselors.
I’ll never talk to you about anything important, and you can’t make me.
This is a shitty little office; you must be a shitty little therapist.
How long will this take?
How old are you? How are you supposed to help me if you’re still in middle school?
In our work with adolescents and young adults, we’ve directly experienced the pleasure (or pain) of being in interviews with people who want little to do with therapy, and nothing to do with us. We’ve had clients refuse to be alone in the room with us, others who refused to speak, a few who insisted on standing, and many who told us with great disdain (and punctuated with profanity) that they don’t believe in counseling.
The first part of this chapter is about interviewing clients who oppose the helping process. It’s also about the deep satisfaction of working with clients who slowly or suddenly shift their attitudes and become cooperative. When these clients eventually enter the room, begin speaking, stop swearing, agree to sit, and begin believing in counseling (and counselors!), it can be a profoundly rewarding experience.
Defining and Exploring Resistance
Freud viewed resistance as inevitable and ubiquitous. Following Freud’s lead, psychotherapists for many years considered virtually anything clients did or said as potential signs of resistance, such as
Talking too much, or talking too little
Arriving late, or arriving early
Being unprepared or overprepared for psychotherapy
The Death (or Reframing) of Resistance
Many theorists and practitioners question the nature and helpfulness of resistance as a concept. In 1984, writing from a solution-focused perspective, Steven de Shazer announced the “death of resistance.” He subsequently held a ceremony and buried it in his backyard. Other theorists and researchers—particularly from culturally diverse perspectives—have followed his lead in viewing resistance differently (Adames et al., 2022; Chimpén-López, C., 2021). They view resistance as an unhelpful linguistic creation that developed because sometimes clients don’t want to (or shouldn’t) do what their “bossy” or oppressive therapist wants them to do (Ratts et al., 2016). In other words, resistance isn’t a problem centered in the client; it’s a problem created by therapists and the power dynamic this presents.
Around the time de Shazer was burying resistance in his backyard, William R. Miller was discovering that reflective listening, empathy, and encouragement with clients who had substance problems, outperformed confrontation and behavioral interventions (W. Miller, 1978, 1983). This discovery led to the development of motivational interviewing (W. Miller & Rollnick, 1991; Miller & Moyers, 2021). Motivational interviewing (MI) is now widely acknowledged as an effective treatment for health, substance, and mental health problems (McKay, 2021; Romano & Peters, 2015).
Resistance is Multidetermined
Unlike the early psychoanalytic position, resistance is neither inevitable or ubiquitous. But it’s probably not dead either. Instead, resistance (aka ambivalence or reluctance) originates from three main sources:
Resistance from the client. Sometimes resistance is real, palpable, and originates from clients’ beliefs, attitudes, ambivalence, or internalized view of therapy as an oppressive situation (Adames et al., 2022). When resistance emanates from clients (regardless of therapist behavior), clients are usually in the precontemplation (not interested in changing) or contemplation (occasional transient thoughts of changing) stages of change (see Chapter 6 for an overview of the transtheoretical stages of change model; Prochaska & DiClemente, 2005).
Resistance that therapists stimulate. Sometimes therapists behave in ways that create resistance rather than cooperation. Overuse of confrontation or interpretation can stimulate client resistance (Romano & Peters, 2015). Therapists who don’t examine and manage their countertransference biases toward particular client populations (e.g., teenage clients, reluctant clients, mandated clients, or clients from diverse cultures), or who perpetuate marginalization of diverse populations, are especially prone to creating client resistance (Ratts, 2017; Tishby & Wiseman, 2020).
Resistance as a function of the situation. Resistance may be a product of a difficult and uncomfortable situation, a situation or expected coercive interpersonal interactions that naturally trigger reactance (i.e., negative expectations and defensiveness; Beutler et al., 2011). Reactance is a well-established psychological phenomenon (Brehm, 1966; Place & Meloy, 2018): When people feel coerced or pushed, they tend to push back, resisting the perceived source of coercion (e.g., therapist). For most mandated clients and for many ambivalent clients, resistance to therapy is a natural, situationally triggered behavior (J. Sommers-Flanagan et al., 2011). Also, for clients with diverse ethnicities or societally-marginalized identities, therapy can naturally feel like the repetition of power-imbalanced colonization experiences (Gone, 2021; Singh et al., 2020).
We realize that framing resistance as multidetermined and natural (or burying it) doesn’t automatically make it easier to handle (J. Sommers-Flanagan & Bequette, 2013). To therapists, resistance can still feel aggressive, provocative, oppositional, and threatening.
It’s unrealistic to expect all clients—especially adolescents or mandated adults in precontemplation or contemplation stages of change—to immediately speak openly and work productively with an unfamiliar authority figure. It’s also unrealistic to expect clients for whom therapy is a new and uncomfortable experience to immediately begin sharing their innermost thoughts. If you use the word resistance, it’s helpful to add the word “natural.” Doing so offers empathy for the client’s entry into an uncomfortable situation and acknowledges the need for strategies and techniques for dealing with client behaviors that are too easily labeled resistant (Hara et al., 2018; Miller & Moyers, 2021). The central question then becomes: What clinician behaviors reduce natural client resistance and defensiveness?
Motivational Interviewing and Other Strategies
In their groundbreaking text, Motivational Interviewing, W. Miller and Rollnick (1991, 2002, 2013) described a practical approach to recognizing and working with client resistance. They emphasized that most humans are ambivalent about personal change because of competing motivations. For example, a client may simultaneously have two competing motivations about smoking cigarettes:
I should quit because smoking is expensive and unhealthy.
I should keep smoking because it’s pleasurable and gives me a feeling of emotional control.
Imagine yourself in an interview situation. You recognize your client is engaging in a self-destructive behavior (e.g., smoking, cutting, punching walls). In response, you educate your client and make a case for giving up the self-destructive behavior. W. Miller and Rollnick (2002) described this classic scenario:
[The therapist] then proceeds to advise, teach, persuade, counsel or argue for this particular resolution to [the client’s] ambivalence. One does not need a doctorate in psychology to anticipate what [the client’s] response is likely to be in this situation. By virtue of ambivalence, [the client] is apt to argue the opposite, or at least point out problems and shortcomings of the proposed solution. It is natural for [the client] to do so, because [he or she] feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence. (pp. 20–21)
In MI, resistance is framed as natural ambivalence about change. Consider this from a physical perspective. If you hold out an open hand and ask someone else to do the same and then push against their hand, the other person usually pushes back, matching your force. During a clinical interview, this process happens verbally. The more you push for healthy change, the more clients push back for staying less healthy (Apodaca et al., 2015).
This leads to the central MI hypothesis for resolving client ambivalence and activating motivation:
This points toward a fundamental dynamic in the resolution of ambivalence: It is the client who should be voicing the arguments for change. (W. Miller & Rollnick, 2002, p. 22, italics added)
But how can clinicians help clients make arguments for change?
MI practitioners refer to clients voicing their own arguments for change as change talk. When clients voice their arguments against change, it’s called sustain talk,because clients are arguing to continue or sustain their unhealthy behaviors. The central hypothesis of MI is that the more clients engage in change talk, positive change is more likely to occur.
MI has relational and technical components. The relational component involves embracing a spirit of collaboration, acceptance, and empathy. Embracing the relational component is crucial, if only because clients who report greater secure attachment to their therapists, also report less resistance (Yotsidi et al., 2019). The technical components include intentional evocation and reinforcement of client change talk (W. Miller & Rose, 2009). In practice, it’s difficult to separate the relational and technical components, and it’s likely more efficacious when they’re delivered together anyway. As you work with reluctant, ambivalent, or so-called resistant clients, you’ll need to make sure your Rogerian person-centered hat is firmly in place, while simultaneously using good behavioral skills to evoke and reinforce change talk.
Using Open Questions, Opening Questions, Evocation, and Goal-Setting Strategies
Open questions are fundamental to MI. However, W. Miller and Rollnick (2013) cautioned asking too many questions, including open questions:
A simple rhythm in MI is to ask an open question and then to reflect what the person says, perhaps two reflections per question, like a waltz. Even with open questions, though, avoid asking several in a row, or you may set up the question-answer trap. (p. 63)
Miller and Rollnick (2013) recommended loosely following their two-to-one waltz metaphor; the point is to do more reflecting than questioning. They offer a stronger warning against repeated closed questions, noting, “Chaining together a series of closed questions can be deadly for engagement” (p. 63).
When opening sessions with clients who may be unenthused to see you, you should use positive, strength-focused, empathic, and non-blaming opening questions:
What brings you here today and how do you hope we might help? (Miller & Moyers, 2021, p. 95)
What would make this a helpful visit?
If we have a great meeting today, what will happen?
What needs to happen in here for our time to be productive?
Open questions and opening questions are especially good tools for evoking clients’ strengths, hope, and solutions (McKay, 2021). Not surprisingly, reluctant clients tend to be more responsive when therapists pursue strengths, rather than pathology. Evocation is a technique used to help clients speak to their resources and strengths. Miller and Moyer (2021) view evocation as inherently containing the message: “You have what you need, and together we’re going to find it (p. 93”). If you’re using open questions to bypass natural resistance, you should aim toward evoking client change talk.
Consider the following example of using a variety of questions to facilitate change talk in an emergency room setting (M. Cheng, 2007, p. 163, parenthetical comments added):
Clinician: What would make today’s … visit helpful? (Clinician asks for goals.)
Patient: I want to kill myself, just let me die… (Patient states unhealthy goal/task.)
Clinician: I’m sure you must have your reasons for feeling that way … What makes you want to hurt yourself? (Clinician searches for underlying healthy goal.)
Patient: I just can’t stand the depression anymore and all the fighting at home. I just can’t take it. (The underlying healthy goals include coping with depression and fighting.)
Clinician: … so we need to find a way to help you cope with the depression and the fighting. You told me yourself that there used to be less fighting at home. What would it be like if we found a way to reduce the fighting, have people getting along more? (Clinician uses past hope to focus on future goal)
Patient: A lot better, I guess. But it’s probably not going to happen. (Client expresses little hope)
Clinician: Okay, I can see why you’re frustrated and I do understand that probably the depression makes it hard to see hope. But I believe that there is a part of you that is stronger and more hopeful, because otherwise you wouldn’t be here talking with me. (Clinician externalizes unhealthy thoughts or behaviors as being part of the depression and tries to help the patient rally against the depression.) That hopeful part of you said that your mood used to be happy. What would it be like if we could get your mood happy again?
Patient: A lot better I guess.
Clinician: Just to help me make sure I’m getting this right then, what would you like to see different with your mood? (The clinician reinforces the client’s goals by having the client articulate them.)
Patient: I want to be happy again.
Clinician: And at home, what would you like to see with how people get along?
Patient: I want us to get along better.
Clinician: Let’s agree then that we will work together on finding a way to help people get along, as well as help your mood get better. How does that sound? (Clinician paraphrases patient’s healthy goals.)
Patient: Sounds good… (Patient agrees with goals.)
In this example, Cheng (2007) illustrated how to help patients articulate goals and potential benefits of positive change (change talk). Although the process began with a negatively worded question—“What makes you want to hurt yourself?”—Cheng listened for positive, health-oriented goals. This is an important principle: Even when exploring emotional pain, you can listen for and resonate with unfulfilled positive goals contributing to that pain.
Using Reflection, Amplified Reflection, and Undershooting
Throughout this text, we’ve emphasized nondirective interviewing skills: paraphrasing, reflection of feeling, and summarizing. Research on MI supports this emphasis, showing that these reflective techniques are powerful tools for working with resistance (McKay, 2021). W. Miller and Rollnick (2002, pp. 100–101) provided examples of simple reflections that reduce resistance:
Client 1: I’m trying! If my probation officer would just get off my back, I could focus on getting my life in order.
Therapist 1: You’re working hard on the changes you need to make. Or,
Therapist 1: It’s frustrating to have a probation officer looking over your shoulder.
Client 2: Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint!
Therapist 2: It’s hard to imagine how I could possibly understand.
Client 3: I couldn’t keep the weight off even if I lost it.
Therapist 3: You can’t see any way that would work for you. Or,
Therapist 3: You’re rather discouraged about trying again.
When therapists accurately reflect client efforts, frustration, hostility, and discouragement, the need for clients to defend their positions is reduced.
Reflections also stimulate talk about the constructive side of ambivalence. While supervising graduate students in counseling and psychology as they conducted hundreds of brief interviews with client-volunteers, we noticed that when student therapists made an inaccurate reflection, the volunteer-clients felt compelled to clarify their feelings and beliefs in ways that rebalanced their ambivalence. For example:
Client: I’m pissed at my roommate. She won’t pick up her clothes or do the dishes or anything.
Therapist: You’d like to fire her as a roommate.
Client: No. Not that. There are lots of things I like about her, but her messiness really annoys me.
This exchange shows the interviewer inadvertently overstating the client’s negative view of the roommate. In response, the client immediately clarifies: “There are lots of things I like about her.”
As it turns out, the interviewer accidentally used an MI technique called amplified reflection (W. Miller & Rollnick, 2013). Amplified reflection involves intentionally overstating the client’s main message. W. Miller and Rollnick wrote: “As a general principle, if you overstate the intensity of an expressed emotion, the person will tend to deny and minimize it, backing off from the original statement” (p. 59).
When used intentionally, amplified reflection can feel manipulative. This is why amplified reflection is used along with genuine empathy and never includes sarcasm. Instead of being a manipulative response, it’s the therapist’s effort to deeply empathize with client frustration, anger, and discouragement. The following are amplified reflections. Scenario 1 involves a mother of a child with a disability and her ambivalence over whether she can take any time for self-care:
Client 1: My child has a serious disability, so I have to be home for him.
Therapist 1: You need to be home 24/7 and turn off any needs you might have to get out and take a break.
Client 1: Actually, that’s not totally true. Sometimes, I think I need to take some breaks so I can do a better job when I’m home.
Scenario 2 involves a college student with ambivalence over giving herself the time and space to grieve her grandmother’s death.
Client 2: When my grandmother died last semester, I had to miss classes and it was a total hassle.
Therapist 2: You don’t have much of an emotional response to your grandmother’s death—other than it’s really inconveniencing you.
Client 2: Well, it’s not like I don’t miss her, too.
Amplified reflection is an empathic effort to fully resonate with one side of the client’s ambivalence; it naturally nudges clients the opposite direction.
It’s also possible to use reflection to understate what clients are saying. W. Miller and Rollnick (2013) refer to this as undershooting. They advocate using it to encourage clients to continue exploring their thoughts and feelings:
Client: I can’t stand it when my mom criticizes my friends right in front of me.
Therapist: You find that a little annoying.
Client: It’s way more than annoying. It pisses me off.
Therapist: What exactly pisses you off about your mom criticizing your friends?
Client: It’s because she doesn’t trust me and my judgment.
In this example, the therapist uses an understatement and then an open question to continue exploring what hurts about the mother’s criticism.
Coming Alongside (Using Paradox)
Intentionally undershooting or using amplified reflections are subtle ways to move client talk in particular directions. A less subtle form of this is paradox. Paradox has traditionally involved prescribing the symptom (Frankl, 1967). For example, with a client who is using alcohol excessively, a traditional paradoxical intervention would involve something like, “Maybe you’re not drinking enough.”
Paradox is a high-risk and provocative intervention. We don’t advocate using traditional paradox. Interestingly, Viktor Frankl, who wrote about paradox in the early 1900s, viewed paradox as operating based on humor. It’s as if clients unconsciously or consciously understand the silliness of behaving in a destructive extreme and consequently pull back in the other direction. Frankl’s formulation might be viewed as working with ambivalence in a manner similar to MI.
W. Miller and Rollnick (2013) discuss using paradox to address resistance, but refer to it as coming alongside. Similar to amplified reflection, coming alongside is used with empathy and respect. The difference between amplified reflection and coming alongside is that in the latter the therapist makes a statement instead of a reflection. Here are two examples:
Client 1: I don’t think this is going to work for me, either. I feel pretty hopeless.
Therapist 1: It’s certainly possible that after giving it another try, you still won’t be any better off, so it might be better not to try at all. What’s your inclination?
Client 2: That’s about it, really. I probably drink too much sometimes, and I don’t like the hangovers, but I don’t think it’s that much of a concern, really.
Therapist 2: It may just be worth it to you to keep on drinking as you have, even though it causes some problems. It’s worth the cost.
Using coming alongside requires authentic empathy for the less healthy side of the ambivalence.
W. Miller and Rollnick (2002) commented on the difference between using coming alongside as compared to traditional paradox:
We confess some serious discomfort with the ways in which therapeutic paradox has sometimes been described. There is often the sense of paradox being a clever way of duping people into doing things for their own good. In some writings on paradox, one senses almost a glee in finding innovative ways to trick people without their realizing what is happening. Such cleverness lacks the respectful and collaborative tone that we understand to be fundamental to the dialectical process of motivational interviewing. (p. 107)
Paradoxical techniques should be delivered along with basic person-centered core attitudes of congruence, unconditional positive regard, and empathic understanding. Paradox shouldn’t be used as a clever means to outwit or trick clients, but to explore the alternative outcome out loud with the client and allow them to respond.
Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback
Clients sometimes begin interviews with hostility, anger, or resentment. If clinicians handle these provocations well, clients may open up and cooperate. The key is to keep an accepting attitude and restrain from lecturing, scolding, or retaliating if clients express hostility.
Empathy, emotional validation, acceptance, and concession can elicit cooperation. We often coach graduate students to use concession when power struggles emerge, especially when working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). If a young client opens a session with “I’m not talking and you can’t make me,” conceding power and control can shift the dynamic: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s perspective and concedes an initial victory in what the client might view as a struggle for power. MI therapists refer to this as affirming the client.
Empathic, emotionally validating statements are also important. If clients express anger about you or therapy, a reflection of feeling and/or feeling validation response communicates that you hear their emotional message. In some cases, you can go beyond empathy and emotional validation and join clients with parallel emotional responses:
I don’t blame you for feeling pissed about having to see me.
I hear you saying you don’t trust me, which is totally normal. You don’t know me, and you shouldn’t trust me until you do.
It sucks to have a judge require you to meet with me.
I know we’re being forced to meet, but we’re not being forced to have a bad time together.
Radical acceptance (RA) is a principle and technique based on person-centered theory and dialectical behavior therapy (Görg et al., 2019). RA involves consciously accepting and actively welcoming all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). Here’s a case where a client began a session with angry statements about counseling:
Opening client volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.
RA return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate counseling but just sit here and pretend to cooperate. I really appreciate your telling me exactly where you’re coming from.
RA can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. One version of this is the love reframe (J. Sommers-Flanagan & Barr, 2005).
Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. Let’s just get this over with.
Therapist: You must really love your daughter to come to a meeting you think is bullshit.
Client: (softening) Yeah. I do love my daughter.
The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone. The love reframe shifts the interview to a more pleasant and cooperative focus.
Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings … pausing … and then following with honest feedback and a solution-focused question.
I hear you saying you hate the idea of talking with me. I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent.] You’re in legal trouble. I want to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour, or we can talk about how you might dig yourself out of this legal hole. I can go either way. What do you think … if we have a good meeting today, what would we accomplish?
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The chapter goes on and on from here, including content on dealing with clients who may be delusional, as well as substance abuse interviewing.
Also, if you want more info, here’s a nice article, albeit dated, where Miller and Rollnick write about 10 things that MI is NOT.
To continue with my plan to feature culturally diverse case examples from the latest edition of Clinical Interviewing, the following excerpt is from Chapter One and focuses on cultural self-awareness. In particular, I LOVE the quotation on intersectionality from Kimberlé Crenshaw.
Cultural Self-Awareness
Those who have power appear to have no culture, whereas those without power are seen as cultural beings, or “ethnic.” (Fontes, 2008, p. 25)
Culture and self-awareness interface in many ways. As Fontes (2008) implied, individuals from dominant cultures tend to be unaware of and often resistant to becoming aware of their invisible and unearned culturally-based advantages (Sue et al., 2020). In the U.S., these “unearned assets” are often referred to as privilege in general, and White privilege in particular (McIntosh, 1998).
Privilege and oppression are best understood in the context of intersectionality. Intersectionality is the idea that overlapping or intersecting social identities within individuals create whole persons that are different from the sum of their parts (Crenshaw, 1989). Social identities that intersect include, but are not limited to: Gender, sexual orientation, sexual identity, race, ethnicity, religion, nationality, mental disorder, physical disability/illness, citizenship, and social class (Hays, 2022). Understanding multiple social identities helps clinicians understand how feelings of oppression can multiply, be activated under distinct circumstances, and be moderated under other circumstances.
Kimberlé Crenshaw (1989, 1991) introduced intersectionality as a lens to facilitate cultural awareness and understanding, but ideas about intersectionality date back at least to Black female abolitionists. In the 1860s, Sojourner Truth articulated Black women’s simultaneous oppression through classism, racism, and sexism (aka “Triple oppression”; Boyce Davies, 2008). Thirty years after she defined intersectionality, Time Magazine asked Crenshaw, “You introduced intersectionality more than 30 years ago. How do you explain what it means today?” (Steinmetz, 2020). She said,
These days, I start with what it’s not, because there has been distortion. It’s not identity politics on steroids. It is not a mechanism to turn white men into the new pariahs. It’s basically a lens, a prism, for seeing the way in which various forms of inequality often operate together and exacerbate each other. We tend to talk about race inequality as separate from inequality based on gender, class, sexuality or immigrant status. What’s often missing is how some people are subject to all of these, and the experience is not just the sum of its parts.
Through the lens of intersectionality, we can develop nuanced ways to have empathy for clients. For example, sometimes clients simultaneously feel privilege and oppression. Thinking and feeling from an intersectional frame can help clinicians be more prepared to view the world from clients’ perspectives (see Case Example 1.2).
CASE EXAMPLE 1.2: EMPATHY FIRST
Maya, an international student of color was in her first practicum. As was her routine, when introducing herself, she acknowledged her accent, her country of origin, along with her eagerness to be of assistance. Her client, a cisgender male university student, was initially polite, but quickly shifted the conversation to his feelings about White privilege, becoming somewhat agitated in the process. He said, “One thing I think you should know that I don’t believe in that White privilege thing. I just came from a class where that’s all everyone was talking about. I know I’m white, but I didn’t get any privilege. I grew up in a trailer park in West Texas. We were what they call ‘White trash.’ Nobody I grew up with had any privilege. We had poverty, abuse, alcoholism, meth, and government bullshit.”
Maya stayed calm. Even though she was activated by her client’s disclosure and was taking some of what he said personally, she focused on empathy first. She also remembered intersectionality and how common it could be for people to have multiple social identities. She said, “I hear you saying that the White privilege concept really doesn’t fit for you. Being in your very last class before coming here made you realize even more that it doesn’t fit. The idea of trying to make it fit feels annoying.”
Maya’s client simply said, “Damn right,” and continued ranting about White privilege, White fragility, and what he viewed as the politically correct environment at the university. As she continued listening and tried feeling along with him, she was able to see glimpses of his personal perspective. Not surprisingly, Maya’s client had social problems related to his tendency to be angry and abrasive. Eventually, after several sessions, they were able to begin talking about what was underneath his agitated emotional response to multicultural ideas and how his tendency to lead with his anger when in conversations with others might be contributing to him feeling even more isolated and different than everyone else. In the end, the client thanked Maya for “being patient with this dumb ass White boy” and helping him learn to be more aware, softer, and less reactive to triggering cultural conversations.
This case illustrates the importance of intersectionality as a concept that can facilitate counselor and client awareness, while also enhancing empathy. Although Maya’s client may have had even worse oppressive experiences had he been a person of color, he was neither interested nor ready to hear that message (Quarles & Bozarth, 2022). Instead, Maya used her knowledge of intersectionality to have empathy with the part of her client’s social identity that had experienced oppression.
Developing cultural self-awareness is difficult. One way of expressing this is to note, “We don’t know what we don’t know.” When someone tries to help us see and understand something about ourselves that’s outside our awareness, it’s easy to feel defensive. Despite the challenges, we encourage you to be as eager for change and growth as possible, and offer three recommendations:
Be open to exploring your own cultural identity. Gaining greater awareness of your ethnicity is useful.
If you’re from the dominant culture, be open to exploring your privilege (e.g., White privilege, wealth privilege, health privilege) as well as hidden ways that you might judge or have bias toward diverse groups and individuals (e.g., transgender, disabled).
If you’re outside the dominant culture, be open to discovering ways to have empathy not only for members within your group, but also for other diversities and for the struggles that dominant cultural group members might have as they navigate challenges of increasing cultural awareness. Engaging in mutual empathy is a cornerstone of relational cultural psychotherapy (Gómez, 2020).
For the next several weeks I’ll be sharing from our almost new 7th edition of Clinical Interviewing.
One of our goals for the 7th edition of Clinical Interviewing is to move toward greater representation of different ethnic/cultural/sexual identities. We want all potential counseling, psychology, and social work students to be able to identify with counseling, psychology, and social work professionals. To accomplish this goal, we added greater representation by broadening our usual chapter content, as well as including case examples contributed by professionals with diverse identities.
Here’s an excerpt from Chapter 1 on culture-specific expertise
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Culture-Specific Expertise
Culture-specific expertise speaks to the need for clinicians to learn skills for working effectively with diverse populations. For example, learning the attitudes and skills associated with affirmative therapy is important for clinicians working with diverse sexualities, including lesbian, gay, bisexual, transgender, queer/questioning (sexual or gender identity), intersex, and asexual/aromantic/agender (LGBTQIA+) clients (Heck et al., 2013). Similarly, integrating skills for talking about spiritual constructs into your work with African American, Latinx, Indigenous, and traditionally religious clients is often essential (Mandelkow et al., 2021; Sandage & Strawn, 2022).
Stanley Sue (1998, 2006) described two general skills for working with diverse cultures: (a) scientific mindedness and (b) dynamic sizing.
Scientific mindedness involves forming and testing hypotheses about client culture, rather than coming to premature conclusions. Although many human experiences are universal, it’s risky to assume you know the underlying meaning of your clients’ behavior, especially minoritized clients. As Case Example 1.3 illustrates, culturally sensitive clinicians avoid stereotypic generalizations.
Dynamic sizing is a complex multicultural concept that guides clinicians on when they should and should not generalize based on an individual client’s belonging to a specific cultural group. For example, filial piety is a value associated with certain Asian families and cultures (Ge, 2021). Filial piety involves the honoring and caring for one’s parents and ancestors. However, it would be naïve to assume that all Asian people believe in or have their lives affected by this particular value; making such an assumption can inaccurately influence your expectations of client behavior. At the same time, you would be remiss if you were uninformed about the power of filial piety in some families and the possibility that it might play a large role in relationship and career decisions in many Asians’ lives. When clinicians use dynamic sizing appropriately, they remain open to significant cultural influences, but they minimize the pitfalls of stereotyping clients.
Another facet of dynamic sizing involves therapists’ knowing when to generalize their own experiences to their clients. S. Sue (2006) explained that it’s possible for clinicians who have experienced discrimination and prejudice to use their experiences to more fully understand the discrimination-related struggles of clients. However, having had experiences similar to a client may cause you to project your own thoughts and feelings onto that client—instead of drawing out the client’s emotions and showing empathy. Dynamic sizing requires that you know and understand and not know and not understand at the same time. Not knowing—or at least not presuming you know—is essential to interviewer-client collaboration.
CASE EXAMPLE 1.3: NOT AT HOME ANYWHERE
In this case, Devika Dibya Choudhuri, Ph.D., LPC (CT/MI), a self-described Buddhist, South Asian, cisfemale, middle-aged, middle-class, Queer, disabled counselor and professor at Eastern Michigan University, illustrates sophisticated cultural-specific expertise in cross-cultural work with a bi-cultural college student. Dr. Choudhuri uses self-disclosure, researches her client’s culture, and integrates culturally meaningful symbols into her sessions. Imagine how you can aspire to be like Dr. Choudhuri.
Darla, a 19-year-old Ghanian-American cisfemale college student, felt something was wrong with her. Her mother was from Ghana, while her father, with whom she had little contact, was generationally African American. She was halting in the first session, trying to decide whether she could trust me, and talking about her recent visit to Accra where her mother’s family lived. I said, “I know when I go to India, I’m American, and when I’m here, I’m Indian. Is it a bit like that for you?” She emphatically replied, “Yes! I’m not at home anywhere!” “Or,” I returned, “almost at home everywhere, like the rest of us global nomads.” She laughed, then spoke far more comfortably about her friends and boyfriend. I had, in that brief exchange, told Darla very important things about me. I self-disclosed casually about my ethnicity and international navigation, normalized her sense of homelessness, while reframing it to join a new group identity.
After having done some research, I asked Darla if her Ghanian kin were the majority Akan or a minority group. She said they were minority. I reflected on whether she might have picked up a sense of marginalization, not just from being Black in America, but also from being minority in Ghana. This became a deep and intense conversation. She reflected on how her American status in Ghana protected her from discrimination, but also alienated her from her cousins.
Another use of culture as intervention came when I brought in Adinkra (visual pictograph meaning saturated symbols originating in Ghana) for her use. Darla chose four to represent her aspirations, and then designed ways to use them in her daily life, incorporating her cultural roots into her present. One of them, Sankofa, is a symbol of the wisdom of learning from the past to build for the future; expressed in the proverb, “it is not taboo to go back for what you left behind.” Feeling grounded in multiple cultures, and being able to navigate from one context to another with her whole and complex self, rather than fragmenting, led her to see she wasn’t “wrong.” Sometimes the spaces were too limited; it was ok to fit and not fit, just as leftover food on a Ghanian table represented abundance.
[End of Case Example 1.3]
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As always, feel free to share your thoughts on and reactions to this content. We’re always looking for practical feedback that will help us continue to become better learners and teachers.
The 7th edition of Clinical Interviewing became available earlier this year. As a part of the text revision, we updated the accompanying videos, videos that Victor Yalom of Psychotherapy.net considers to be the best of their kind. And, possibly having watched more professional training videos than anyone on the planet, Victor knows what he’s talking about, and we are humbled by his endorsement.
Videos that accompany the text cover 72 learning objectives and are extensive. The bad news is that they usually, but not always, feature me. The good news is that in our video revision and upgrade, we included numerous counselors/psychotherapists of color. . . so it’s not just all me talking about how to develop your clinical interviewing skills.
If you watch them, I hope you enjoy the videos. And, if you feel so moved, please share your reactions or suggestions with me here or via email: john.sf@mso.umt.edu.
Lately, when presenting, I find myself naturally saying, “I’m a university professor. That means I can talk all day long.”
But because I know that me talking too much is a bad idea, I complement my university professor disclosure with, “I’d rather have a conversation, so please interrupt me with comments, questions, and reactions.” I also try to offer an experiential learning or reflection activity.
In group class, I have so many stories to tell that I can feel my already prodigious talking urges escalate. I could unleash my breathless wordy-self for three straight hours. The students would leave having been entertained (I am funny), and with a bit of knowledge, but without skills for running counseling groups.
All this circles back to my plan to make the course as experiential as possible. I want students to feel the feelings of being in the group facilitator chair. Some of those feelings will be nerves, but it’s better for students to feel more nerves in group class, and fewer nerves when they’re leading real groups.
We recently hit Day 1 of the transformative experiential chaos.
I know from the takeaways that students write me every week that there were nerves. In a fishbowl group, I asked members to share one positive interpersonal quality. As a second and optional prompt, I suggested they could also share one less positive interpersonal quality.
My goal was for us to briefly look at and talk about Yalom’s concept of interpersonal learning.
I shared first (to demo leader self-disclosure and modeling); I intentionally described a positive and less positive interpersonal quality. The first student to disclose felt instant awareness of the past, present, and future. Afterward, she described feeling a burden to follow my lead, anxiety in the moment, along with instant recognition that she was about to become a role model. She shared both (a positive and less positive interpersonal quality). Everyone followed her lead. Some members felt more anxiety when sharing the positive qualities; for others, it was the opposite.
One takeaway involved the speed and power of norm-setting. I’m reminded of the social psych compliance research. More or less, people consciously or less consciously feel the “norm” and comply. The corollary takeaway is that when leaders set the norm, we need to do so carefully so as to not imply everyone needs to fall in line.
Jumping ahead, the next week I discussed Kelman’s theory of group cohesion. Although I absolutely love Yalom’s definition (“Cohesion is the attraction of the group for its members”), Kelman’s theory is complementary, and was introduced to my be my 1975 Mount Hood Community College football coach. Kelman (and my coach) identified three phases: Compliance, Identification, and Internalization. After talking about Kelman’s theory, several students reflected in their email takeaways about the nature of cult groups. . . and how compliance can become leader-driven. Wow. So good.
In response to one student’s takeaway, part of my email included the following:
“For groups to be safe, IMHO, that also means freedom; freedom to have dissenting beliefs and different experiences and different values. The “internalization” shouldn’t be too tight, or it does feel like a cult. I’m not sure I have great answers about safeguards to the abuse of group processes, and so you’ve given me things to chew on as well.”
Maybe the right recipe is for there to be leader-guided modeling, combined with clear rules and norms that support independent thinking and personal freedom. This is a VERY tricky balance. It’s easy for leaders (including me) to get too enamored with the sound of our own voices and the rightness of our own values.
This brings me back to reflecting on how much leaders should talk and how much leaders should listen. Of course, this depends on the type of group: psychoeducational groups involve more group leader talking. In contrast, counseling groups—even discussion-based groups or support groups—benefit from the group talking more and the leader talking less. This has been a repeated epiphany for students and for me: being aware of the need to balance leader-talk and leader modeling with group member talk and group member modeling.
For the next class, I gave everyone an electronic copy of a long list of 23 group counseling skills to integrate into one of their experiential groups. Here’s the list:
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.
Imagine the possibility of a scalable single-session intervention that has been shown to be effective with a wide range of mental health issues. In these days of widespread mental health crisis and overwhelmed healthcare and mental health providers, you might think that effective single-session interventions are a fantasy. But maybe not.
This morning, my older daughter emailed me a link to two videos from the lab of Dr. Jessica Schleider of Northwestern University. Dr. Schleider’s focus is on single-session therapeutic interventions. Although I hadn’t seen the website and videos, I was familiar with Dr. Schleider’s work and am already a big fan. Just to give you a feel for the range and potential of single-session interventions, below I’m sharing a bulleted list of titles and dates of a few of Dr. Schleider’s recent publications:
Realizing the untapped promise of single‐session interventions for eating disorders – 2023
In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: A randomized controlled trial – 2023
A randomized trial of online single-session interventions for adolescent depression during COVID-19 – 2022
An online, single-session intervention for adolescent self-injurious thoughts and behaviors: Results from a randomized trial – 2021
A single‐session growth mindset intervention for adolescent anxiety and depression: 9‐month outcomes of a randomized trial – 2018
Reducing risk for anxiety and depression in adolescents: Effects of a single-session intervention teaching that personality can change – 2016
Single-session therapy or interventions aren’t for everyone. Many people need more. However, given the current mental health crisis and shortage of available counselors and psychotherapists, having a single-session option is a great thing. As you can see from the preceding list, single-session interventions have excellent potential for effectively treating a wide range of mental health issues. Given this good news about single-session interventions, I’m now sharing with you that link my daughter shared with me: https://www.schleiderlab.org/labdirector.html
I’ve been interested in single-session interventions for many years. Just in case you’re interested, here’s a copy of my first venture into single-session research (it’s an empirical evaluation of a single-session parenting consultation intervention, published in 2007).
Every chapter in Clinical Interviewing has several pop-out boxes titled, “Practice and Reflection.” In this–the latest–edition, we added many that include the practice and perspective of diverse counselors and psychotherapists. Here’s an example from Chapter One.
PRACTICE AND REFLECTION 1.3: AM I A GOOD FIT? NAVIGATING ETHNIC MATCHING IN PRIVATE PRACTICE
The effects of ethnic matching on counseling outcomes is mixed. In some cases and settings, and with some individuals, ethnic matching improves treatment frequency, duration, and outcomes; in other cases and settings, ethnic matching appears to have no effects in either direction (Olaniyan et al., 2022; Stice et al., 2021). Overall, counseling with someone who is an ethnic/cultural match is meaningful for some clients, while other clients obtain equal meaning and positive outcomes working with culturally different therapists.
For clients who want to work with therapists who have similar backgrounds and experiences, the availability of ethnically-diverse therapists is required. In the essay below, Galana Chookolingo, Ph.D., HSP-P, a licensed psychologist, writes of personal and professional experiences as a South Asian person in independent practice.
On a personal note, being from a South Asian background in private practice has placed me in a position to connect with other Asians/South Asians in need of culturally-competent counseling. In my two years in solo private practice, I have had many individuals reach out to me specifically because of my ethnicity and/or the fact that I am also an immigrant to the U.S. (which I openly share on my website). These individuals hold an assumption that I would be able to relate to a more collectivistic worldview. Because I offer free consultations prior to meeting with clients for an intake, I have had several clients ask directly about my ability to understand certain family dynamics inherent to Asian cultures. I have responded openly to these questions, sharing the similarities and differences I am aware of, as well as my limitations, since I moved to the U.S. before age 10. For the most part, I have been able to connect with many clients of Asian backgrounds; this tends to be the majority of my caseload at any given time.
As you enter into the multicultural domain of counseling and psychotherapy, reflect on your ethnic, cultural, gender, sexual, religious, and ability identities. As a client, would you prefer working with someone with a background or identity similar to yours? What might be the benefits? Alternatively, as a client, might there be situations when you would prefer working with someone who has a background/identity different than yours? If so, why and why not?
Reflecting on Dr. Chookolingo’s success in attracting and working with other Asian/South Asian people . . . what specific actions did she take to build her caseload? How did she achieve her success?
[End of Practice and Reflection 1.3]
For more info on ethnic matching, see these articles:
Olaniyan, F., & Hayes, G. (2022). Just ethnic matching? Racial and ethnic minority students and culturally appropriate mental health provision at British universities. International Journal of Qualitative Studies on Health and Well-being, 17(1), 16. doi:https://doi.org/10.1080/17482631.2022.2117444
Stice, E., Onipede, Z. A., Shaw, H., Rohde, P., & Gau, J. M. (2021). Effectiveness of the body project eating disorder prevention program for different racial and ethnic groups and an evaluation of the potential benefits of ethnic matching. Journal of Consulting and Clinical Psychology, 89(12), 1007-1019. doi:https://doi.org/10.1037/ccp0000697
John Sommers-Flanagan 