Tag Archives: Emotion

Clinical Interviewing, Group counseling, Group therapy, Writing

Working with Emotions in Counseling and Psychotherapy: Part 2

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In my last post, I reviewed the most basic of all therapeutic emotional responses, the reflection of feeling. As noted yesterday, reflections of feeling are, by definition, neutral . . . and providing a neutral reflection has benefits and liabilities.

For clients who have a history of experiencing negative judgments and oppression, instead of remaining neutral, it may be necessary to be explicitly validating. In Chapter 5 of our Clinical Interviewing textbook, we begin by describing and providing examples of the technique called “Feeling Validation.”

If you’re tracking closely, you’ll recall that a reflection of feeling is on the left side of the “listening continuum” and feeling validation is in the center of the listening continuum. Below, you’ll find information on using feeling validation from the Clinical Interviewing text.

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Directive Listening Skills

Directive listening skills are advanced interviewing techniques that encourage clients to examine and possibly change their thoughts, emotions, and behaviors. Directive listening skills can be used for assessment, exploring client issues, and facilitating insight. They include:

  • Feeling validation
  • Interpretive reflection of feeling
  • Interpretation (psychoanalytic or reframing)
  • Confrontation
  • Immediacy
  • Questions

Directive listening skills place you in an expert role. The therapist’s behaviors in this chapter range from being mostly client centered to mostly therapist centered. Client-centered directives zero in on what the client is already talking about, but take clients deeper. Therapist-centered directives shift clients toward what they’re not yet talking about. Directive listening skills operate on the assumption that clients will benefit from guidance or direction.

Feeling Validation

Reflections of feeling (discussed in Chapter 4) are often confused with feeling validation. The difference is that reflections of feeling are more purely client centered, whereas feeling validation includes your opinion, approval, or validation of client emotions. A feeling validation is an emotion-focused technique that acknowledges and validates your client’s explicit feelings. It’s a message that communicates, “What you’re feeling is a natural or normal emotional response.” Feeling validation is an emotional affirmation.

The difference between reflecting feelings versus validating feelings may seem subtle, but it provides an excellent example of the complexities of skillful interviewing. Skilled interviewers use reflection of feeling as a method to prompt clients to evaluate their own emotions. In contrast, they use feeling validation as a method to support and reassure clients. Feeling validation includes a psychoeducational-authoritative-reassurance component. Novice interviewers may not be aware of the difference.

Psychoanalytic clinicians distinguish between supportive and expressive psychotherapy techniques. Based on this distinction, feeling validation is a supportive technique, and feeling reflection is an expressive technique. Clients usually feel supported and more normal when you validate their emotions. Clients may experience greater stress if you use reflections of feeling to have them examine and judge the validity of their own emotions.

Supportive techniques like feeling validation are outside-in self-esteem boosters. They’re based on the therapist (as an outside authority) saying something like “Your anger in response to being unfairly accused of stealing something seems natural.” One drawback of outside-in self-esteem boosters is that they don’t facilitate self-discovery. The boost that comes from external emotional validation may be temporary and not lead to lasting client change. If clients come to rely on validation of their feelings, they may continue to look outward for external validation.

All approaches to feeling validation give clients the message, “Your feelings are acceptable, and you have permission to feel them.” You might even use feeling validation to suggest to clients that they should be having particular feelings.

Client 1: I’ve been so sad since my mother died. I can’t seem to stop myself from crying. (Client begins sobbing.)

Therapist 1: It’s okay to feel sad about losing your mother. That’s perfectly normal. Crying in here as you talk about it is a natural response.

The preceding exchange involves validation. By openly stating that feeling sad and crying is normal, the therapist takes on an expert or educator role.

Another way to provide feeling validation is through self-disclosure:

Client 2: I get so anxious before taking tests, you wouldn’t believe it! All I can think about is how I’m going to freeze up and forget everything. Then, when I get to class and look at the test, my mind just goes blank.

Therapist 2: I remember feeling the same way about tests.

In this example, the therapist uses self-disclosure to validate the client’s anxiety. Although using self-disclosure to validate feelings can be reassuring, it’s not without risk. Clients may wonder if therapists can be helpful with anxiety symptoms if they have similar anxieties. Self-disclosure can also enhance therapist credibility, as a client may think, “Hmm. If my therapist went through test anxiety too, maybe he’ll understand and be able to help me.” Using self-disclosure to validate client emotions can diminish or enhance therapist credibility—depending on the client and the therapeutic relationship (see Case Example 5.1).

Therapists can also use universality to validate or reassure clients.

Client 3: I always compare myself to everyone else—and I usually come up short. I wonder if I’ll ever feel confident.

Therapist 3: You’re being hard on yourself. I don’t know anyone who feels a complete sense of confidence.

Clients may feel validated when they observe or are informed that nearly everyone else in the world (or universe) feels similar emotions. Yalom provided a personal example:

During my own 600-hour analysis I had a striking personal encounter with the therapeutic factor of universality… I was very much troubled by the fact that, despite my strong positive sentiments [towards my mother], I was beset with death wishes for her, as I stood to inherit part of her estate. My analyst responded simply, “That seems to be the way we’re built.” That artless statement not only offered considerable relief but enabled me to explore my ambivalence in great depth. (Yalom & Leszcz, 2020, p. 7)

Feeling validation is a common technique. People like to have their feelings validated; and, often, counselors like validating their clients’ feelings. However, open support, such as feeling validation, can reduce client exploration of important issues (i.e., clients assume they’re fine if their therapist says so).

Potential effects of feeling validation include:

  • Enhanced rapport
  • Increased or reduced client exploration of the problem or feeling (this could go either direction)
  • Reduction in client anxiety, at least temporarily
  • Enhanced client self-esteem or feelings of normality (perhaps only temporarily)
  • Possible increased client-therapist dependency

In many clinical scenarios, clinicians lead with less directive skills (i.e., Chapter 4) before using more directive skills (i.e., Chapter 5). However, there are some clinical situations where feeling validation or affirmation of clients take priority.

As you think about feeling validation, and all the complexities it can include, consider the following case example.

CASE EXAMPLE 5.1: Struggling to Manage the Impulse to Project My Disability Issues onto a Client

Eddy Fagundo, Ph.D., CRC, CVE, a Senior Manager of Education Content for the American Counseling Association wrote an essay on managing his impulse to project his own issues and lived experiences onto a client. Have you ever worked with someone who reminded you of yourself? Imagine yourself in Dr. Fagundo’s role. Would you be able to manage your impulses to be too comforting and too validating? Although this case is about countertransference, projection, and overidentification with the client, it’s also about appropriately validating self-disclosure and countertransference management.

“Mommy Rosemary, why does Eddy speak Russian?’” was an odd question that had become common for my friends (at age 5-years) to ask my mother . . . in Cuba. What my friends did not know was that I was not speaking Russian; I was speaking Spanish, or so I thought! Growing up, I had speech problems, but was determined to overcome them. I never missed any of my speech therapy appointments and was disciplined in practicing the difficult Spanish rolling Rs in front of the mirror before and after school. I did it! In third grade, I won the best reader in class award. Life was bright. Little did I know, that four years later, I would immigrate to the United States, and learn a new language. But I did this too!

These memories flashed before my eyes when counseling a young Cuban immigrant male with a speech impediment. The client felt defeated, isolated, and had low expectations of himself. I was conflicted; this young man was me as a child. If I could overcome my speech problems, I wanted to tell him: He could too! At the time, I was a new rehabilitation counselor. The situation made me keenly aware of potential projection issues. I knew I could not tell the client what to do. I knew I could not tell him he would be able to succeed, just as I did, because I was no more special than he was.

And so, I consulted my colleagues and supervisor. I focused on being aware of and bracketing my feelings and reactions, and on building a therapeutic relationship. I accepted the client unconditionally and respected his right to be himself without having me project my lived experiences onto him. Instead, I used my lived experiences therapeutically by professionally and appropriately self-disclosing my past struggles with speech problems. Counselor self-disclosure, when done sparingly and effectively, builds trust, fosters empathy, and strengthens the counseling relationship.

Today, the client is fully fluent in what some would argue to be the true universal language: mathematics. He holds a doctorate in mathematics, the speech impediments are improved, and he lives a fulfilling life. Even today, I wonder how different the outcome would have been had I not had the self-awareness and professional support to counter my projection impulses.

We will encounter clients similar to us in ways that make us struggle to avoid projecting our own lived experiences onto them. We need to identify those clients, but to do so, we must first ask, “Who am I, and who is standing beside me to support me in this journey of self-discovery?”

[End of Case Example 5.1]

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Our Clinical Interviewing text also includes specific learning activities. If you want to check out a learning activity designed to add nuance to your feeling (emotional) vocabulary, check out this handout:

practice-and-reflection-emotionsDownload
Clinical Interviewing, Group counseling, Group therapy, Happiness, Writing

Working with Emotions in Counseling and Psychotherapy – Part 1

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We’ve been talking about emotions in our Group Counseling course at the University of Montana. Even though focusing on emotions has grown immensely in popularity within contemporary counseling and psychotherapy, some students seem to be missing a few basics. Last week, when I took time to talk about the differences between (a) reflection of feeling, (b) interpretive reflection of feeling, and (c) feeling validation most of the students found the information useful. Consequently, I’m including here (and in a following blog post or two) excerpts from the latest edition of our Clinical Interviewing textbook. https://www.wiley.com/en-us/Clinical+Interviewing%2C+7th+Edition-p-9781119981985

The foundation that guides how clinicians respond to clients is described in our “Listening Continuum” (see below).

the-listening-continuum-in-three-partsDownload

This excerpt is from the section in Chapter 4 on Reflection of Feeling.  

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Reflection of Feeling (aka Empathy)

The primary purpose of a reflection of feeling is to let clients know, through an emotionally focused paraphrase, that you’re tuned in to their emotional state. Nondirective reflections of feeling encourage further emotional expression. Consider the following example of a 15-year-old male (he/him) talking about his teacher:

Client: That teacher pissed me off big time when she accused me of stealing her phone. I wanted to punch her.

Counselor: You were pretty pissed off.

Client: Damn right.

In this example, the feeling reflection focuses only on what the client clearly articulated. This is the rule for nondirective feeling reflections: Restate or reflect only the emotional content that you clearly heard the client say. No probing, interpreting, or speculation are included. Although we might guess at underlying dynamics contributing to this boy’s fury, a nondirective feeling reflection focuses on obvious emotions.

Emotions are personal. Every attempt to reflect feelings is a move toward closeness or intimacy. Some clients who don’t want relational connection with you may react negatively to reflections of feeling. You can minimize negative reactions to reflections of feeling by phrasing them tentatively, especially during an initial interview:

When using reflection to encourage continued personal exploration, which is the broad goal of reflective listening, it is often useful to understate slightly what the person has offered. This is particularly so when emotional content is involved. (W. R. Miller & Rollnick, 2013, p. 59)

Emotional accuracy is your ultimate goal. However, if you miss the emotional target, it’s better to miss with an understatement than an overstatement. If you overstate emotional intensity, clients will often backtrack or deny their feelings. As we’ll discuss in Chapter 12, there’s a proper time to intentionally overstate client emotions. Generally, however, you should aim for accuracy while proceeding tentatively and understating rather than overstating clients’ emotions. Rogers (1961) would sometimes use clarification with clients after giving a reflection of feeling (e.g., “I’m hearing sadness and pain in your voice… am I getting that right?”).

If you understate a reflection of feeling, your client may correct you.

Client: That teacher pissed me off big time when she accused me of stealing her watch. I wanted to punch her.

Counselor: Seems like you were a little irritated about that. Is that right?

Client: Irritated? Fuck no—I was pissed.

Counselor: You were way more than irritated. You were pissed.

In this example, a stronger emotional descriptor is better because the client expressed more than irritation. However, any adverse effect of “missing” the emotion is minimized because the counselor phrased the reflection tentatively with “Seems like…” and then added a clarifying question at the end. Then, perhaps most important, when the client corrected the counselor, the counselor repaired the reflection to fit with the client’s emotional experience. From a psychoanalytic perspective, the repairing of emotional mirroring or empathy might be the most therapeutic part of listening (Kohut, 1984; see Practice and Reflection 4.3 to practice emotional responses to clients).

Reflections of feeling are often labeled as empathy. If only empathy were so simple. As Clark noted, “Rogers . . . was appalled by this . . . as the rich and nuanced process of empathy was reduced to trivial and repetitive expressions of a therapist identifying a client’s feelings” (p. 23). As we move forward through this chapter and other content on more directive interviewer responses, remember that empathy should be woven into nearly every therapist utterance, including confrontation, advice, and behavioral homework (Clark, 2023). 

With clients, mental health professionals engage in emotional clarification, exploration, validation, and education. Your role varies depending on your clients’ needs and situation. As a technique, reflection of feeling aids clients in clarifying and exploring their emotions.  For this chapter and reflection of feeling, the best path is a tentative one, wherein you function as a mirror to help clients experience and articulate their emotions with greater clarity. Doing so can serve to help clients explore and gain greater understanding of their emotional worlds. To accomplish your interviewing goals, you don’t need to know everything about the academic and popular debates over emotions; instead, you partner with clients to deepen your mutual understanding of the emotional experiences. 

[Several pages of the text are skipped here]

Gender, Culture, and Emotion

Imagine you’re in an initial clinical interview with a Latino (he/him) cisgender male husband and father. He looks unhappy and your impression is that he’s angry about his wife’s employment outside the home. You’re aware that some Latine/x people have traditional ideas about male and female family roles. This knowledge provides you with a foundation for using a reflection of feeling to focus on his anger:

I’m getting the sense that you’re a little angry about your wife deciding to go back to work.

He responds,

Nah. She can do whatever she wants.

You hear his words. He seems to be empowering his wife to do as she pleases. But his voice is laden with annoyance. This leads you to try again to connect with him on a deeper level. You say,

Right. But I hear a little annoyance in your voice.

This reflection of feeling prompts an emotional response, but not the one you hoped for.

Sure. You’re right. I am annoyed. I’m fucking annoyed with you and the fact that you’re not listening to me and keep focusing on all this feelings shit.

This is a dreaded scenario for many clinicians. You take a risk to reflect what seems like an obvious emotion, and you get hostility in return. Your emotional sensitivity and effort at empathy backfires. The client moves to a defensive and aggressive place, and a relationship rupture occurs (see Chapter 7 for more on dealing with relationship ruptures).

It’s tempting to use culture and gender to explain this client’s negative reaction to your reflection of feeling. But it’s not that simple.

Although culture, gender, race, and other broad classification-based variables can sometimes predict whether specific clients will be comfortable with emotional expression, individual client differences are probably more substantial determinants. Comfort in expressing emotion is often a function of whether the client comes from a family-neighborhood-cultural context where emotional disclosure was a norm. For example, Knight (2014) reported that Black and Latino males who were unlikely to disclose to their peers attributed this tendency to their experiences living in violent communities. These young men learned that emotional expression and trusting others were bad ideas in their neighborhoods. Conversely, emotional disclosure is more likely in the comfort range of Black and Latine/x males raised in safer communities. This makes good common sense: Whether clients perceive you as safe to talk with about emotional concerns probably has more to do with their backgrounds and past experiences than you.

Overall, it’s likely that clients’ willingness to tolerate feeling reflections is based on a mix of their cultural, gender, and individual experiences. Although biogenetics may be involved too, how people handle emotions is largely socialized (McDermott et al., 2019). If you have reason to suspect that your client is socialized to be uncomfortable with emotions, you should avoid emotionally specific words. Examples of emotionally specific words include angry, sad, scared, and guilty.

Instead of emotionally specific words, you can substitute words that are emotionally vague (and less intense). Later, as trust develops, you might be able to use specific emotional words. Consider the following phrases:

  • You found that frustrating.
  • It seems like that bothered you a bit.
  • It’s a little upsetting to think about that.

Practice and Reflection 4.4 lists examples of emotionally vague words you might use instead of emotionally specific words.

PRACTICE AND REFLECTION 4.4: USING VAGUE AND EMOTIONALLY SAFE WORDS

Emotionally Specific WordsSubstitute (Safer) Words
AngryFrustrated, upset, bothered, annoyed
SadDown, bad, unlucky, “that sucked”
ScaredBothered, “didn’t need that,” “felt like leaving”
GuiltyBad, sorry, unfortunate, “bad shit”

Note: These words may work as substitutes for more emotionally specific words, but they also may not. It will be more effective for you to work with your classmates or in your work setting to generate less emotionally threatening words and phrases that are culturally and locally specific.

[End of Practice and Reflection 4.4]

Gender diverse clients may be emotionally sensitive in ways different than clients on the gender binary. Due to their neutrality, reflections of feeling—even when accurate—can be activating if clients are sensing you’re coming from a place of judgment. Consider the following:

Counselor: You said your family is rejecting your sexual identity, and you’re feeling terribly sad about that.

Client: Wouldn’t you?

When clients have a substantial history of interpersonal rejection, emotional invalidation, and/or oppression, neutral comments from clinicians can be perceived as judgmental. In this exchange, the counselor uses an accurate simple paraphrase along, with an emotional reflection, but the client feels judged and responds defensively. Given the client’s history, feeling judged in response to neutral reflections is natural. What the client needs (to feel connected and supported) is a response that’s explicitly affirming or validating (Alessi et al., 2019). In this case, at least until rapport is established, rather than a feeling reflection, the client would likely react better to a feeling validation (“Your sadness in response to your family’s rejection of your sexual identity seems totally normal”; see Chapter 5 for information on feeling validations). 

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Thanks for reading. In the coming week, there will be additional posts on the basics and nuances of working with emotions in counseling and psychotherapy.

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Uncategorized

Emotional Dysregulation: Finding the Way Out

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Sometimes we call it affect dysregulation. It creeps around like a metaphorical tarantula, sometimes popping up—big and frightening—and always best viewed from a distance. Just like shit, emotional dysregulation happens.

In counseling and psychotherapy, we throw around jargon. It can be more or less helpful. When it’s helpful, it facilitates important communication; when it’s not, it distances us from the experiences of our clients, students, and other mental health consumers.

So what is emotional dysregulation? Here’s what Wikipedia says:

Emotional dysregulation (ED) is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response. ED may be referred to as labile mood (marked fluctuation of mood) or mood swings.

I hereby declare that definition not very helpful.

I have a better definition. Emotional dysregulation (ED) is the term of the month. Why? Because I’ve been intermittently emotionally dysregulated since November 9 and I see emotional dysregulation nearly everywhere I look.

I’ve seen many clients for whom the term emotionally dysregulated is an apt description. These clients report being frequently triggered or activated (more jargon) by specific incidents or experiences. Many of these incidents are interpersonal, but as many of us know from the recent election, they can also be political and, for many, reading about or directly experiencing social injustice is a big trigger. After being emotionally triggered, the person (you, me, or a client) is left feeling emotionally uneasy, uncomfortable, and it can be hard to regain emotional equilibrium, calm, or inner peacefulness.

What are common emotional dysregulators? These include, but are certainly not limited to: Being misunderstood, experiencing social rejection or social injustice, harassment, or bullying, or being emotionally invalidated. Consider these (sometimes well-meaning) comments: “Smile.” “What’s wrong with you?” “You’re overreacting.” “Chill.” “Cheer up.”). One time I overheard a father tell his son, “Do you think I give a shit about what you’re feeling?” Yep. If someone says that to you or you overhear someone saying it to a 10-year-old, that might trigger emotional dysregulation.

Emotional dysregulation passes. That’s the good news. But sometimes it doesn’t pass soon enough. And other times, like when I see he-who-will-not-be-named on the television screen or hear his voice on the radio, repeated re-activation or re-triggering can occur. It becomes the Ground Hog’s Day version of emotional dysregulation.

In the clinical world, emotional dysregulation is linked to post-traumatic stress disorder, borderline personality disorder, clinical depression, and a range of other anxiety disorders. Suicidal crises often have emotional triggers. The point: emotional dysregulation is a human universal; it occurs along a continuum.

The Fantastic Four

Emotional dysregulation usually involves one of the fantastic four “negative” emotions. These include:

  • Anger
  • Sadness
  • Fear
  • Guilt

To be fair, these emotions aren’t really negative. They have both negative and positive characteristics. In every case, they can be useful, sooner or later, to the person experiencing them. For example, anger is both light and energy. It can clarify values and provide motivation or inspiration. Unfortunately, the light and energy of anger is also confusing and destabilizing. It’s easy for anger to cloud cognition; it’s easy for anger to send people out on misguided behavioral missions. Funny thing, these misguided, anger-fueled missions often feel extremely self-righteous, right up until the point they don’t. Less funny thing, immediately after the punch, the flip-off, the profanity, the broken window or door or relationship or whatever—regret often follows. Ironically then, the emotional dysregulation (anger) leads to behavioral dysregulation (aggression), which leads right back to emotional dysregulation (guilt and remorse).

Dysregulation can be experienced via any of a number of dimensions. You can experience behavioral, mental, social, and spiritual dysregulation. What fun! Who designed this system where we can get so dysregulated in so many different ways? Never mind. It was probably he-who-will-not-be-named.

One of the most perplexing things about emotional dysregulation is that so very often, we do it to ourselves. We do it repeatedly. And more or less, we usually know we’re doing it. We seem to want to embrace our anger, sadness, fear, and guilt. What’s wrong with that? Nothing, that is, until we want out.

For most people, the fantastic four feel bad. They stay too long. They adversely affect relationships. They’re bad company.

There’s one best way out of emotional dysregulation. I’ll say it in a word that I’m borrowing from Alfred Adler. Gemeinschaftsgefühl. I’ll say it in another word: Empathy. Empathy for yourself and others. The kind of empathy that moves you to being interested in other people and motivated to help make our communities and the world better, safer, and more filled with justice.

Okay then. Let’s get out there and start Gemeinschaftsgefühling around. We’ve got at least four years of work ahead.

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For another, less profound way out of the Fantastic Four negative emotions, check out the Three-Step Emotional Change Trick: https://johnsommersflanagan.com/2012/09/23/the-three-step-emotional-change-trick/

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