Hi All,
Here are my slides for today. I hope you all have a fantastic Friday.
Tag Archives: Psychotherapy
Who Are You? A Request
We’re in the throes of editing our Theories text, meaning I’m so deep into existential, feminist, and third wave counseling and psychotherapy theories that I may have lost myself. If any of you find me somewhere on the street babbling about Judith Jordan and Frantz Fanon and Bryan Cochran, please guide me home.
This brings me to a big ask.
As part of 4th wave feminism, we’re more deeply integrating intersectionality into the practice of feminist therapy. Among other things, intersectionality is about identity. I’m interested in using a variation of Irvin Yalom’s “Who are you?” group technique to explore identity in anyone willing to respond to this post.
To participate, follow these instructions.
- Clear a space for thinking, writing, and exploring your identity.
- Ask yourself the question: “Who am I?” and write down the response as it flows into your brain/psyche.
- Repeat this process nine more times, for a total of 10 responses, numbering each response. One rule about this: You can’t use the same response twice.
- After you finish your list of 10, write a paragraph or two about how you were affected by this activity.
- If you’re comfortable sharing, send me your list of 10 identities along with your reflections (email: john.sf@mso.umt.edu). If you prefer the more public route, you can post your responses here on my blog. Either way, because I’m in 24/7 theories mode, you may not hear back from me until middle November!
There’s a chance I might want to quote one or more of you in the theories text, instructor’s manual, student guide, or in this blog. If that’s the case, I will email you and request permission.
Thanks for considering this activity and request. Identity and identity development are fascinating. Whether we’re talking about multiple identities (intersectionality), emotions and behaviors (Blake), or the “microbes within us” (Yong), we all contain multitudes.
Revisiting the Genius of Mary Cover Jones
While reviewing and revising the behavior therapy chapter from our Theories textbook, I found myself revisiting my awe of Mary Cover Jones. I think too many contemporary therapists don’t know about Mary Cover Jones and don’t understand the behavioral (classical conditioning) model for understanding and treating anxiety disorders, including OCD and PTSD.
In most chapters, we include a feature called a “Brain Box.” Here’s the box from Chapter 7, Behavior Theory and Therapy.
7.1 Brain Science May be Shiny, but Exposure Therapy is Pure Gold
In honor of Joseph Wolpe, let’s start with mental imagery.
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Imagine you’ve travelled back in time to your first week of high school. You look around and see that one of your classmates is named Mary Jones.
Mary is an ordinary girl with an ordinary name. Over the years, you don’t notice her much. She seems like a nice person, a fairly good student, and someone who doesn’t get in trouble or draw attention to herself.
Four years pass. A new student joined your class during senior year. His name is Daniel Tweeter. Toward the end of the year, Daniel does a fantastic Prezi presentation about a remarkable new method for measuring reading outcomes. He includes cool video clips and boomerang Snapchat. When he bows at the end, he gets a standing ovation. Daniel is a good student and a hard worker; he partnered up with a college professor and made a big splash. Daniel deserves recognition.
However, as it turns out, over the whole four years of high school, Mary Jones was quietly working at a homeless shelter; week after week, month after month, year after year, she was teaching homeless children how to read. In fact, based on Daniel’s measure of reading outcomes, Mary had taught over 70 children to read.
Funny thing. Mary doesn’t get much attention. All everybody wants to talk about is Daniel. At graduation, he wins the outstanding graduate award. Everyone cheers.
Let’s stop the visualization and reflect on what we imagined.
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Like birds and raccoons, humans tend to like shiny things. Mary did incredible work, but hardly anyone noticed. Daniel did good work, and got a standing ovation and the top graduate award.
The “shiny-thing theory” is my best explanation for why we tend to get overly excited about brain science. It’s important, no doubt, but brain imaging isn’t therapy; it’s just a cool way to measure or validate therapy’s effects.
Beginning from at least 1924, when Mary Cover Jones was deconditioning fear out of little children, behavior therapy has shown not only great promise, but great outcomes. However, when researchers showed that exposure therapy “changes the brain,” most of the excitement and accolades were about the brain images; exposure therapy was like background noise. Obviously, the fact that exposure therapy (and other therapies) change the brain is great news. It’s great news for people who have anxiety and fear, and it’s great news for practitioners who use exposure therapy.
This is all traceable to neuroscience and human evolution. We get distracted by shiny objects and miss the point because our neural networks and perceptual processes are oriented to alert us to novel (new) environmental stimuli. This is probably because change in the form of shiny objects might signal a threat or something new and valuable. We therefore need to exercise self-discipline to focus in and not overlook that behavior therapy in general, and exposure therapy in particular, has been, is, and probably will continue to be, the most effective approach on the planet for helping people overcome anxiety and fear. In addition, you know what, it doesn’t really matter that it changes the brain (although that’s damn cool and affirming news). What matters is that it changes clients’ lives.
Exposure therapy, no matter how you package it, is highly effective for treating anxiety. This statement is true whether we’re talking about Mary Cover Jones and her evidence-based counterconditioning cookies or Francine Shapiro and eye movement desensitization reprocessing (EMDR). It’s also true whether we’re talking about virtual reality exposure, imaginal exposure, massed exposure, spaced exposure, in vivo exposure, interoceptive exposure, response prevention (in obsessive-compulsive disorder), or the type of exposure that acceptance and commitment therapists use (note that they like to say it’s “different” from traditional classical conditioning exposure, but it works, and that’s what counts).
In the end, let’s embrace and love and cheer brain imaging and neuroscience, but not forget the bottom line. The bottom line is that exposure therapy works! Exposure therapy is the genuine article. Exposure therapy is pure gold.
Mary Cover Jones is the graduate of the century; she was amazing. Because of her, exposure therapy has been pure gold for 93+ years, and now we’ve got cool pictures of the brain to prove it.
Mary Cover Jones passed away in 1987. Just minutes before her death, she said to her sister: “I am still learning about what is important in life” (as cited in Reiss, 1990).
We should all be more like Mary.
Today’s Rabbit Hole: What Constitutes Scientific Evidence for Psychotherapy Efficacy?
On July 24, in Helena, I attended a fun and fascinating meeting sponsored by the Carter Center. I spent the day with a group of incredibly smart people dedicated to improving mental health in Montana.
The focus was twofold. How do we promote and establish mental health parity in Montana and how do with improve behavioral health in schools? Two worthy causes. The discussions were enlightening.
We haven’t solved these problems (yet!). In the meantime, we’re cogitating on the issues we discussed, with plans to coalesce around practical strategies for making progress.
During our daylong discussions, the term evidence-based treatments bounced around. I shared with the group that as an academic psychologist/counselor, I could go deep into a rabbit-hole on terminology pertaining to treatment efficacy. Much to everyone’s relief, I exhibited a sort of superhuman inhibition and avoided taking the discussion down a hole lined with history and trivia. But now, much to everyone’s delight (I’m projecting here), I’m sharing part of my trip down that rabbit hole. If exploring the use of terms like, evidence-based, best practice, and empirically supported treatment is your jam, read on!
The following content is excerpted from our forthcoming text, Counseling and Psychotherapy Theories in Context and Practice (4th edition). Our new co-author is Bryan Cochran. I’m reading one of his chapters right now . . . which is so good that you all should read it . . . eventually. This text is most often used with first-year students in graduate programs in counseling, psychology, and social work. Consequently, this is only a modestly deep rabbit hole.
Enjoy the trip.
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What Constitutes Evidence? Efficacy, Effectiveness, and Other Research Models
We like to think that when clients or patients walk into a mental health clinic or private practice, they will be offered an intervention that has research support. This statement, as bland as it may seem, would generate substantial controversy among academics, scientists, and people on the street. One person’s evidence may or may not meet another person’s standards. For example, several popular contemporary therapy approaches have minimal research support (e.g., polyvagal theory and therapy, somatic experiencing therapy).
Subjectivity is a palpable problem in scientific research. Humans are inherently subjective; humans design the studies, construct and administer assessment instruments, and conduct the statistical analyses. Consequently, measuring treatment outcomes always includes error and subjectivity. Despite this, we support and respect the scientific method and appreciate efforts to measure (as objectively as possible) psychotherapy outcomes.
There are two primary approaches to outcomes research: (1) efficacy research and (2) effectiveness research. These terms flow from the well-known experimental design concepts of internal and external validity (Campbell et al., 1963). Efficacy research employs experimental designs that emphasize internal validity, allowing researchers to comment on causal mechanisms; effectiveness research uses experimental designs that emphasize external validity, allowing researchers to comment on generalizability of their findings.
Efficacy Research
Efficacy research involves tightly controlled experimental trials with high internal validity. Within medicine, psychology, counseling, and social work, randomized controlled trials (RCTs) are the gold standard for determining treatment efficacy. RCTs statistically compare outcomes between randomly assigned treatment and control groups. In medicine and psychiatry, the control group is usually administered an inert placebo (i.e., placebo pill). In the end, treatment is considered efficacious if the active medication relieves symptoms, on average, at a rate significantly higher than placebo. In psychotherapy research, treatment groups are compared with a waiting list, attention-placebo control group, or alternative treatment group.
To maximize researcher control over independent variables, RCTs require that participants meet specific inclusion and exclusion criteria prior to random assignment to a treatment or comparison group. This allows researchers to determine with greater certainty whether the treatment itself directly caused treatment outcomes.
In 1986, Gerald Klerman, then head of the National Institute of Mental Health, gave a keynote address to the Society for Psychotherapy Research. During his speech, he emphasized that psychotherapy should be evaluated through RCTs. He claimed:
We must come to view psychotherapy as we do aspirin. That is, each form of psychotherapy must have known ingredients, we must know what these ingredients are, they must be trainable and replicable across therapists, and they must be administered in a uniform and consistent way within a given study. (Quoted in Beutler, 2009, p. 308)
Klerman’s speech advocated for medicalizing psychotherapy. Klerman’s motivation for medicalizing psychotherapy partly reflected his awareness of heated competition for health care dollars. This is an important contextual factor. Events that ensued were an effort to place psychological interventions on par with medical interventions.
The strategy of using science to compete for health care dollars eventually coalesced into a movement within professional psychology. In 1993, Division 12 (the Society of Clinical Psychology) of the American Psychological Association (APA) formed a “Task Force on Promotion and Dissemination of Psychological Procedures.” This task force published an initial set of empirically validated treatments. To be considered empirically validated, treatments were required to be (a) manualized and (b) shown to be superior to a placebo or other treatment, or equivalent to an already established treatment in at least two “good” group design studies or in a series of single case design experiments conducted by different investigators (Chambless et al., 1998).
Division 12’s empirically validated treatments were instantly controversial. Critics protested that the process favored behavioral and cognitive behavioral treatments. Others complained that manualized treatment protocols destroyed authentic psychotherapy (Silverman, 1996). In response, Division 12 held to their procedures for identifying efficacious treatments but changed the name from empirically validated treatments to empirically supported treatments (ESTs).
Advocates of ESTs don’t view common factors in psychotherapy as “important” (Baker & McFall, 2014, p. 483). They view psychological interventions as medical procedures implemented by trained professionals. However, other researchers and practitioners complain that efficacy research outcomes do not translate well (aka generalize) to real-world clinical settings (Hoertel et al., 2021; Philips & Falkenström, 2021).
Effectiveness Research
Sternberg, Roediger, and Halpern (2007) described effectiveness studies:
An effectiveness study is one that considers the outcome of psychological treatment, as it is delivered in real-world settings. Effectiveness studies can be methodologically rigorous …, but they do not include random assignment to treatment conditions or placebo control groups. (p. 208)
Effectiveness research focuses on collecting data with external validity. This usually involves “real-world” settings. Effectiveness research can be scientifically rigorous but doesn’t involve random assignment to treatment and control conditions. Inclusion and exclusion criteria for clients to participate are less rigid and more like actual clinical practice, where clients come to therapy with a mix of different symptoms or diagnoses. Effectiveness research is sometimes referred to as “real world designs” or “pragmatic RCTs” (Remskar et al., 2024). Effectiveness research evaluates counseling and psychotherapy as practiced in the real world.
Other Research Models
Other research models also inform researchers and practitioners about therapy process and outcome. These models include survey research, single-case designs, and qualitative studies. However, based on current mental health care reimbursement practices and future trends, providers are increasingly expected to provide services consistent with findings from efficacy and effectiveness research (Cuijpers et al., 2023).
In Pursuit of Research-Supported Psychological Treatments
Procedure-oriented researchers and practitioners believe the active mechanism producing positive psychotherapy outcomes is therapy technique. Common factors proponents support the dodo bird declaration. To make matters more complex, prestigious researchers who don’t have allegiance to one side or the other typically conclude that we don’t have enough evidence to answer these difficult questions about what ingredients create change in psychotherapy (Cuijpers et al., 2019). Here’s what we know: Therapy usually works for most people. Here’s what we don’t know: What, exactly, produces positive changes.
For now, the question shouldn’t be, “Techniques or common factors?” Instead, we should be asking “How do techniques and common factors operate together to produce positive therapy outcomes?” We should also be asking, “Which approaches and techniques work most efficiently for which problems and populations?” To be broadly consistent with the research, we should combine principles and techniques from common factors and EST perspectives. We suspect that the best EST providers also use common factors, and the best common factors clinicians sometimes use empirically supported techniques.
Naming and Claiming What Works
When it comes to naming and claiming what works in psychotherapy, we have a naming problem. Every day, more research information about psychotherapy efficacy and effectiveness rolls in. As a budding clinician, you should track as much of this new research information as is reasonable. To help you navigate the language of researchers and practitioners use to describe “What works,” here’s a short roadmap to the naming and claiming of what works in psychotherapy.
When Klerman (1986) stated, “We must come to view psychotherapy as we do aspirin” his analogy was ironic. Aspirin’s mechanisms and range of effects have been and continue to be complex and sometimes mysterious (Sommers-Flanagan, 2015). Such is also the case with counseling and psychotherapy.
Language matters, and researchers and practitioners have created many ways to describe therapy effectiveness.
- D12 briefly used the phrase empirically validated psychotherapy. Given that psychotherapy outcomes vary, the word validated is generally avoided.
- In the face of criticism, D12 blinked once, renaming their procedures as empirically supported psychotherapy. ESTs are manualized and designed to treat specific mental disorders or specific client problems. If it’s not manualized and doesn’t target a disorder/problem, it’s not an EST.
- ESTs have proliferated. As of this moment (August 2025), 89 ESTs for 30 different psychological disorders and behavior problems are listed on the Division 12 website (https://div12.org/psychological-treatments/). You can search the website to find the research status of various treatments.
- To become proficient in providing an EST requires professional training. Certification may be necessary. It’s impossible to obtain training to implement all the ESTs available.
- In 2006, an APA Presidential Task Force (2006) loosened D12’s definition, shifting to a more flexible term, Evidence-Based Practice (EBP), and defining it as ‘‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences’’ (p. 273).
- In 2007, the Journal of Counseling and Development, the American Counseling Association’s flagship journal, inaugurated a new journal section, “Best Practices.” As we’ve written elsewhere, best practice has grown subjective and generic and is “often used so inconsistently that it is nearly meaningless” (Sommers-Flanagan, 2015, p. 98).
- In 2011, D12 relaunched their website, relabeling ESTs as research-supported psychological treatments (n.b., most researchers and practitioners continue to refer to ESTs instead of research-supported psychological treatments).
- As an alternative source of research updates, you can also track the prolific work of Pim Cuijpers and his research team for regular meta-analyses on psychological treatments (Cuijpers et al., 2023; Harrer et al., 2025).
- Other naming variations, all designed to convey the message that specific treatments have research support, include evidence-based treatment, evidence-supported treatment, and other phrasings that, in contrast to ESTs and APA’s evidence-based practice definition, have no formal definition.
Manuals, Fidelity, and Creativity
Manualized treatments require therapist fidelity. In psychotherapy, fidelity means exactness or faithfulness to the published procedure—meaning you follow the manual. However, in the real world, when it comes to treatment fidelity, therapist practice varies. Some therapists follow manuals to the letter. Others use the manual as an outline. Still others read the manual, put it aside, and infuse their therapeutic creativity.
A seasoned therapist (Bernard) we know recently provided a short, informal description of his application of exposure therapy to adult and child clients diagnosed with obsessive-compulsive disorder. Bernard described interactions where his adult clients sobbed with relief upon getting a diagnosis. Most manuals don’t specify how to respond to clients sobbing, so he provided empathy, support, and encouragement. Bernard described a therapy scenario where the client’s final exposure trial involved the client standing behind Bernard and holding a sharp kitchen knife at Bernard’s neck. This level of risk-taking and intimacy also isn’t in the manual—but Bernard’s client benefited from Bernard trusting him and his impulse control.
During his presentation, Bernard’s colleagues chimed in, noting that Bernard was known for eliciting boisterous laughter from anxiety-plagued children and teenagers. There’s no manual available on using humor with clients, especially youth with overwhelming obsessional anxiety. Bernard used humor anyway. Although Bernard had read the manuals, his exposure treatments were laced with empathy, creativity, real-world relevance, and humor. Much to his clients’ benefit, Bernard’s approach was far outside the manualized box (B. Balleweg, personal communication, July 14, 2025).
As Norcross and Lambert (2018) wrote: “Treatment methods are relational acts” (p. 5). The reverse is equally applicable, “Relational acts are treatment methods.” As you move into your therapeutic future, we hope you will take the more challenging path, learning how to apply BOTH the techniques AND the common factors. You might think of this—like Bernard—as practicing the science and art of psychotherapy.
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Note: This is a draft excerpt from Chapter 1 of our 4th edition, coming out in 2026. As a draft, your input is especially helpful. Please share as to whether the rabbit hole was too deep, not deep enough, just right, and anything else you’re inspired to share.
Thanks for reading!
Counseling and Psychotherapy Theories: The 4th Edition Revision is Underway
At long last, we’ve begun work on revising our Counseling and Psychotherapy Theories text for its 4th edition. Over the past several weeks, I’ve been putting in an hour or two a day, chipping away on chapter revisions, reaching out to reviewers, and planning with our new and very exciting co-author, Dr. Bryan Cochran, a highly esteemed psychology professor at the University of Montana. If you’re reading this, I want you to know of Bryan’s awesomeness (and if you’re Bryan, I want you to feel the pressure of this public announcement of your awesomeness) [hahahaha!]
You all probably know that our Theories textbook is far and away the Theories textbook with the most hilarity. No doubt, this is a rather low bar, given that I can’t find any funny stories in any other theories texts. We view theories hilarity to be extremely important in a theories text, because reading many theories texts can parallel the proverbial experience of watching paint dry.
Bryan’s addition to the writing team will give us something we need—an expert in the LGBTQ+ domain, and someone with a talent for telling stories that are simultaneously engaging, informative, and fun to read. Right now, he’s busy writing a “Lenses” chapter (to be Chapter 2) to orient readers to important theory-related lenses like (a) Queer theory, (b) Critical Race theory, (c) Intersectionality, and more. I, for one, can hardly wait for his Queer theory quips.
News Flash: In the past, I’ve put out broad calls for chapter reviewers. This time, I’m being selective and directly asking prominent theories experts to review chapters and offer guidance. Some examples: For the Adlerian chapter we’ve got Marina Bluvshtein (woohoo!) and Jon Sperry (wow!). For the Psychoanalytic chapter, we got Nancy McWilliams (amazing!) and Pratyusha Tammala-Narra (fantastic!).
If you happen to be a specific theories subject matter expert, you should email me at john.sf@mso.umt.edu to get in on the fun. Or if you have a prominent theories friend/colleague to recommend, have them email me.
As one last theories teaser, below I’m pasting a few excerpts from Nancy McWilliams’s 2021 article titled, “Diagnosis and Its Discontents: Reflections on Our Current Dilemma.” I love this article as it gives a glimpse into problems with contemporary diagnoses and how psychodynamic therapists use individualized assessment in ways to honor the real-life complexities clients bring into psychotherapy. The excerpts below are from her article, which is linked at the end of this post.
On Labeling
The idea that one is anxious (or depressed or obsessive) about something that has meaning is being lost. Fitting an individual into a category tends to foreclose exploration of what is unique to a patient; it especially prevents insights into unexpected aspects of a person’s psychology or exploration of areas that are felt as shameful – the very areas that are of particular value in planning and carrying out psychotherapy.
On the vexing ways in which patients think about themselves and their diagnoses
It used to be that a socially avoidant woman would come for therapy saying something like, “I’m a painfully shy person, and I need help learning how to deal better with people in social situations.” Now a person with that concern is likely to tell me that she “has” social phobia – as if an alien affliction has invaded her otherwise problem-free subjective life. People talk about themselves in acronyms oddly dissociated from their lived experience: “my OCD,” “my eating disorder,” “my bipolar.” There is an odd estrangement from one’s sense of an agentic self, including one’s own behavior, body, emotional and spiritual life, and felt suffering, and consequently one’s possibilities for solving a problem. There is a passive quality in many individuals currently seeking therapy, as if they feel that the prototype for making an internal psychological change is to describe their symptoms to an expert and wait to be told what medicine to take, what exercises to do, or what self-help manual to read.
On “chemical imbalances”
. . . viewing psychological suffering as a set of disorders that can be fixed or improved chemically can easily invite the obverse assumption that those painful experiences are ultimately caused by random or genetically based chemical differences among individuals. This is a false conclusion, of course, something like saying that because marijuana improves appetite, the cause of low appetite is lack of marijuana. But it is nevertheless a frequent leap of illogic – in the thinking of nonprofessionals and of some professionals as well – to ascribe much severe psychological suffering to a “chemical imbalance.” Such a construction tempts us to ignore all the painful other sources of psychological suffering, such as poverty, neglect, trauma, and the myriad ways in which human beings can injure each other psychologically.
On not overgeneralizing research findings/recommendations to unique patients
. . . consider patients at the extreme end of the obsessive-compulsive continuum, whose obsessions border on delusional beliefs, who suffer profound annihilation anxiety, who wholeheartedly believe they will die if they fail to carry out their rituals, and who regard the therapist with suspicion for not sharing their conviction – in other words, the subgroup of obsessive patients that Kernberg (1984) would consider as psychologically organized at the low borderline or psychotic level. My experience suggests that with this group exposure therapy not only fails, it demoralizes the patients, makes them feel like failures personally, and kills any hope they may have that psychotherapy can help. It also demoralizes therapists, who have been told again and again that exposure therapy is the treatment of choice for OCD. If they believe their teachers, such clinicians can easily conclude they are simply not good enough therapists.
If I’ve piqued your interest in “Diagnosis and its discontents” by Nancy McWilliams, here’s a pdf of the article.
Stay tuned for more theories revision (we’re calling it T4) updates.
John SF
Two Upcoming Events
Hi All,
I’ve got two events coming up, one sooner and one later.
This Friday, I’m doing the closing talk for Tamarack’s Grief Institute (which is on Thursday and Friday in Missoula, and available online too!).
This is late notice, as the end of day tomorrow (March 3) is the registration deadline. The whole Institute is worth attending. The fantastic Dr. Joyce Mphande-Finn kicks things off on Thursday morning. Then, the amazing Dr. Micki Burns takes over . . . and I’ll be bringing it home Friday afternoon. Check it out. Here’s a registration link:
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This June, I have the incredible fortune of joining Dr. Jeff Linkenbach and the renowned Montana Summer Institute in Big Sky, Montana (and Livestream) from June 17-20. Here’s a description of what’s happening!
Reimagining Community Health:
Uncovering Positive Norms and & Activating Hidden
Protective Factors
In Big Sky, Montana and via Livestream: June 17-20, 2025
Join us at the 2025 Montana Summer Institute for three and a half transformative days dedicated to advancing community well-being. Through thought-provoking keynotes, interactive workshops, and engaging discussions, you’ll explore innovative strategies that leverage positive norms and amplify protective factors.
Learn to uncover hidden community strengths, identify untapped opportunities, and craft impactful communications that drive meaningful change. With insights from leading experts and experienced practitioners, you’ll gain practical tools to reimagine your approach to data, messaging, and the people you serve—all through a positive, effective frame.
Don’t miss this opportunity to expand your expertise, deepen your impact, and shape healthier, more resilient communities. For more information, visit www.montanainstitute.com
Is there any chance you will join us in June? It would be wonderful to have you there! Here is the Montana Discount Code to give $100 off the price: MSIMONT which would give $100 off registration
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And here’s a fancy flyer for the Montana Summer Institute:
The One-Way Mirror Project and Self-Reflection: A Process of Pain and Growth
This post is for my Chinese friends, or my friends who speak Mandarin . . . or anyone who wants to read about the process of self-evaluation, the pain of self-reflection, and personal/professional growth.
Last year I was asked to participate as a psychotherapist for the One-Way Mirror Project. The project was inspired by the old and now classic “Three Approaches to Psychotherapy” videos. Not surprisingly, I was honored to be asked to participate, and said yes despite a number of challenging factors, including doing therapy late at night with a Chinese woman via Zoom. I share this because this post is about transparency and so I’m transparently beginning by making excuses for not being the best therapist I imagine myself to be.
Here’s the scenario: One session. Minimal pre-meeting information. Post-session viewing (by me) and commentary on my performance. One other therapist also met with the same client. I get to watch his session; he gets to watch mine. We then have a Zoom meeting to debrief and share our thoughts about our respective sessions (mine was in English; his was in Mandarin).
This was a super-interesting process.
Below, I’m sharing my written self-reflection comments. There’s also a video version . . . which is similar to, but not verbatim from, these notes. The comments are numbered sequentially.
I hope you enjoy this self-reflection/analysis. Thanks for reading.
John S-F – Commentary on His Session with Evelyn
- My first reaction to watching this video of myself was embarrassment. I’m sharing this reaction because it’s true. I don’t want to pretend that I think this is a particularly good session.
- That said, I also don’t think it was a particularly bad session. I did some things well, and some things less well. In this commentary I will try to describe: (a) what I’m doing (or trying to do), especially from different theoretical perspectives, (b) how Evelyn is responding, (c) what I’m doing well and what I’m doing that’s much less good.
- In critiquing my own work, I’m also hoping to connect with all of you. Whether you’re a beginning student or an experienced professional psychotherapist, watching ourselves and hearing ourselves can be humbling and embarrassing. It’s natural for all of us to make mistakes and be imperfect . . . and in this session I do an excellent job of being imperfect😊. . . so much so that while watching the video, during several points I kept shouting at myself to “shut up!” So, that’s a glimpse into one thing I would change about MY behavior in this session. Although I’m okay with being imperfect, I’m not very comfortable with being as imperfect as I was in this session.
- How I Work – 0:10 – This explanation has three main goals. First, I’m showing transparency, which is consistent with person-centered and feminist therapies. Second, I’m explaining the process of our session, which is a role induction designed to help clarify expectations. Third, I’m including an invitation for collaboration.
- SFBT Opening Question – 1:30 – “If we have a useful meeting, what will we accomplish?” This is a goal-oriented question to help me be more aware of Evelyn’s vision of a successful session.
- Evelyn’s Goal – 1:50 – Evelyn says she wants a “different perspective” of what she’s worried about.
- JSF’s Goal – In a single session treatment, and maybe most therapy sessions, it’s best to begin with what the client wants. Evelyn’s goal is a “cognitive goal.” In this moment, I decide to go with George Kelly’s “Credulous approach to assessment,” which essentially means “believe the client.” That could be a variation of Carl Rogers’s assertion that we should “Trust the client, because the client knows what hurts and where to go.” JSF – Your goal is my goal, as long as it’s legal and healthy.”
- What I Know – 2:25 – This is another effort to be like Carl Rogers and show transparency.
- Feelings and Thoughts Around That – 3:00 – Here, I’m trying to prompt her to explore feelings and/or thoughts. She says, “So many worries overwhelming” and talks about not knowing what is overwhelming and then references social media, and four main issues/worries: (a) Fitness/body image/comparison, (b) feelings of unfairness related to gender issues, (c) she loves her partner, but “he is a man” (with sarcasm, implying he therefore cannot understand), (d) humiliation linked to breasts filling with milk involuntarily.
- A Broad Summary/Paraphrase – I respond with an accurate summary of her four “feelings and thoughts”
- “You can choose; I cannot” – 7:10 – Evelyn focuses on the inherent sex/gender unfairness as related to having a baby. In response, we discuss the burden of social responsibility and how she has internalized societal expectations around being a woman.
- May I Share an Observation? – 8:30 – At this point, I try to be a mirror that reflects back to Evelyn what I’m experiencing as one of her positive attributes or strengths. When working across cultures, it’s especially important to be affirming of client strengths. I end this reflection using first-person pronouns—which is a language skill that Rogers used and called “Walking within” – 9:10
- Evelyn Continues – 10:45 – to talk about feeling powerless and influenced by her age, generation, societal expectations, and then notes that she wants to “make peace with what she wants to be and what she can be.” The thought of having a baby is a particular trigger for her anxious thoughts and fears. – 11:15
- An Intellectual Grasp – 12:15 – I observe that Evelyn has a good intellectual grasp of feminism and of her internalized expectations about how women should be.
- A Reflection and SFBT Question – 12:35–13:29 – Using too many words, I finally get out a “Unique outcomes” question: “How have you dealt with internalized fears and conflicts before?”
- I Love That Question – 13:35 – Evelyn reflects on a story from age 24 and provides examples of how she felt time running out, dated like crazy, was very brave, and fought back toward her goal of a loving relationship even after having her heart broken.
- How did you manage? – 15:03 – I continue to pursue Evelyn’s pre-existing strengths and insights around, with a bit of a focus on what motivated her to “fight back.”
- As a Good Therapist – 15:35 – Evelyn expresses motivation to be a good therapist and that requires expansive live experiences.
- Anything Else Pull You – 16:54 – Evelyn shares an early fear of death, noting, after an anecdote, that her class presentation on death left her feeling “more lonely (or different) than ever.” – 17:54. [not psychoanalytic]
- I Reflect – 18:30 – Being a better therapist and fear of death motivate her to live a life full of experiences.
- Imagine self at end of life – 19:00 – Found someone I love and would like to have a child. I want to try it. That would complete my experience. – 19:30
- Values vs. Anxieties – 19:55 – Still feel anxieties. “I have to carry a child” etc. . . walking within. Amplifying expectations so she can hear them.
- That’s my barrier –
- Fought those off those expectations before – 20:45 – And yet . . . you have fought off expectations before. What makes you think you will be a victim to those expectations in the future? Here, I’m trying to identify what CBT people might consider an “irrational” or “maladaptive” thought/belief that doesn’t have much evidence to support it. Also, exception. . .
- Focus on the Physical/Somatic – 22:25 – Evelyn notes this task is “harder” and supports that with physical changes she’s experiencing with aging. . . and I interpret that as “Anticipatory grief” regarding her physical decline [this is likely death anxiety too]
- Self-Disclosure – 23:40 – May I share something? “I have a 35-y/o daughter with similar issues.” [Too many words! Should have stopped when Evelyn laughed and put her hand to her face and then explored her initial reaction]. I finally get to “What’s your reaction?” [Late, but I got there]. She says . . . and this is potentially central to “one” therapy goal: “I feel, like, less lonely.” [Again, I should just stop there or repeat it back. . . or “What’s it like inside to feel less lonely?”].
- Curious about what I could learn from her – 25:35 – I turn this around. Why? Because I want her to value herself as a source of wisdom.
- When I share with my partner – 26:25 – She notes “he can relate” and that “men are limited.” [This could have been good transference exploration or Adlerian basic mistake]
- Session shift to “so much feeling” – 27:16 – Evelyn is talking about her emotionality, I’m reflecting ok. More on unfairness, but notes BF is pretty accepting. I do a strength-based reflection, “Openness, strength, do not run from feelings!” This is a little CBT as I want her to “perceive” herself with more strengths to cope with her future challenges.
- Thoughts about yourself? – 31:00 – I’ve been working on some CBT stuff and now am shifting back to the important self-evaluation process. Her response is constructive as she describes lots of planning she has already done for this coming year.
- I want to hear out my fears – 32:10 – This is a great insight on her part. It prompts me to have her listen to her fears in the here and now. Evelyn responds [33:10] that she likes that question and explores, perhaps with a tiny bit of surprise, that her fears are not harsh, but more of a gentle reminder to not have regrets. [Here, I could and probably should have had her get deeper into here and now processing. “Let’s have you hear the gentle voice of your fear right now. What’s it saying to you? Say it as if you are the fear. Also, could have used repetition.]
- Reflections and WW – I stay with the themes and use WW to keep bringing them back. Why? In part, desensitization. Hearing her anxiety-producing words in a potentially trusting/comforting setting can take some edge or power out of them [MCJ – 1924]. She says, somewhat conclusively, “Sounds like fear just wants me to get prepared and not critique.” [One thought, I could have been her child and asked her to tell me what she has learned.]
- Evelyn asks JSF Q – 36:28 – This is one place where I fall off the rails. She asked me a question and my obnoxious, intellectual, professor-self emerges. . . for far too long. [I could have said, “I have some thoughts about that, but I’d like to hear yours first.”] Instead, JSF blah, blah, blah, and to compound the error, I do not check in on her reaction.
- Evelyn continues exploring – 40:52 – She notes Yuval Harrare and feminism as a new way to resolve conflicts without war. I do manage to shift back to listening with a pretty good paraphrase: “Communication with your partner may be your best way to grow and develop and maintain your feminist identity through childbirth and your relationship.”
- Evelyn recognizes perfect equality not possible – 42:35 – JSF “Love what you said. What do you think? How does it feel?” [2 Qs, boo, but my focus on her self-evaluation is still pretty solid.] I continue with “What’s your assessment of yourself and your communication skills?” I’m hoping she can express trust in her communication skills.
- Non-violent communication as restraint – 46:00 – This is an interesting side road where E says, “Sometimes I just want to be violent and like a child” and notes that she prefers “emotionally charged communication.” She finds emotions and aggressive communication to be helpful. [Note: at this point I’m beginning to feel time pressure. No time to go deeper. If more sessions, I’d earmark this and close. Instead, I ask, “Is it ok to have both” (nonviolent and emotional communication) as a quick prompt toward integration.
- Moving toward closing – 49:00 – I’ve lost track of time because of early tech problems. I’d like to think that’s my excuse for ending poorly. First, I begin a summary. This isn’t good. It’s MY summary . . . and I should be asking for HER summary before offering mine. I’m far too verbal. The content isn’t terrible.
- Thank-you so much – 52:45 – She’s tracking time, and this should be it. I’m not. And do another disclosure and ask for her summary.
- Closing – 56:40 – Awkward. Not smooth. Not good.
The Handout for this Friday’s Strengths-Based Suicide Workshop
Sorry for all the posts, but apparently there’s lots happening in early 2025.
The big NEWS post won’t be until tomorrow.
As you know, on this Friday, January 10, I’ll be doing an online, two-hour workshop on Strategies for Integrating Traditional and Strengths-Based Approaches to Suicide for the Cognitive Behavior Institute.
I’m posting the workshop handouts here, in advance, for anyone interested.
You may recall that this workshop is ALMOST FREE. Only $25. There’s still time to register here:
I hope to see you there!
Questions (and Mindfulness) in Counseling and Psychotherapy
Every day, I keep getting older. I can’t seem to stop myself. And every day, I keep running into dialectics. They’re everywhere. My aging experiences of ubiquitous dialectics seems consistent with the fact that yesterday, Merriam-Webster declared “polarization” their word of the year (https://www.merriam-webster.com/wordplay/word-of-the-year).
Boo, Merriam-Webster! I would have chosen dialectics. Here’s one of the definitions for dialectic listed in the online M-W dictionary: “the Hegelian process of change in which a concept or its realization passes over into and is preserved and fulfilled by its opposite.” TBH, I have very little understanding of what the heck Hegel was talking about, but I’m pretty sure it’s happening ALL. THE. TIME.
This morning I find myself plagued by the idea that although most mental health professionals advocate mindfulness, many mental health professionals (including myself, sometimes), aren’t very mindful when using basic counseling skills in practice. Today’s topic is questions. I’m polarized inside a dialectical and thinking, “We should all be more mindful and intentional in our use of questions in counseling and psychotherapy.” At the same time, I’m sure, “we should all relax and be more of ourselves.”
With these confusing caveats in mind, today, tomorrow, and maybe the next day, I’m posting about the very basic use of questions in counseling and psychotherapy. This content is excerpted from our Clinical Interviewing textbook.
Here’s our opening section on questions, which is conveniently found in Chapter 5 of Clinical Interviewing, which I’m continually surprised that not everyone has read (but really not at all surprised).
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Questions
Imagine digging a hole without a shovel or building a house without a hammer. For many clinicians, conducting an interview without using questions constitutes an analogous problem: How can you complete the interviewing task without using your most basic tool?
Despite the central role of questions in clinical interviewing, we’ve avoided discussing them until now. Similarly, when teaching clinical interviewing skills, we usually prohibit question asking for a significant portion of the course (J. Sommers-Flanagan & Means, 1987). Our rationale includes several factors: Questions are easy and often misused. Also, because questioning isn’t the same thing as listening, our goal is for students to develop alternative information-gathering strategies. Asking questions can get in the way of gathering important information from clients. The Little Prince expresses a fundamental problem with excessive questioning.
Grown-ups love figures. When you tell them that you have made a new friend, they never ask you any questions about essential matters. They never say to you, “What does his voice sound like? What games does he love best? Does he collect butterflies?” Instead, they demand: “How old is he? How many brothers has he? How much does he weigh? How much money does his father make?” Only from these figures do they think they have learned anything about him. (de Saint-Exupéry, 1943/1971, p. 17)
The questions you ask may be of no value to the person being asked. Ideally, your questions should focus on what seems most important to clients.
Despite our reservations about excessive questioning, questions are a diverse and flexible interviewing tool; they can be used to
- Stimulate client talk
- Inhibit client talk
- Facilitate rapport
- Show interest in clients
- Show disinterest in clients
- Gather information
- Confront clients
- Focus on solutions
- Ignore the client’s viewpoint
- Stimulate insight
There are many forms or types of questions. Differentiating among them is important, because different question types produce different client responses. In this section, we describe open, closed, swing, indirect, and projective questions. Chapter 6 covers therapeutic questions. Although we distinguish between general question types and therapeutic questions, all questioning can be used for assessment or therapeutic purposes.
Open Questions
Open questions are used to facilitate talk; they pull for more than a single-word response. Open questions ordinarily begin with either How or What. Sometimes questions that begin with Where, When, Why, and/or Who are classified as open, but such questions are only partially open because they don’t facilitate talk as well as How and What questions (Cormier, Nurius, & Osborn, 2017). The following hypothetical dialogue illustrates how using open questions may or may not stimulate client talk:
Therapist: When did you first begin having panic attacks?
Client: In 1996.
Therapist: Where were you when you had your first panic attack?
Client: I was just getting on the subway in New York City.
Therapist: What happened?
Client: When I stepped on the train, my heart began to pound. I thought I was dying. I just held on to the metal post next to my seat because I was afraid I would fall over and be humiliated. I felt dizzy and nauseated. I’ve never been back on the subway again.
Therapist: Who was with you?
Client: No one.
Therapist: Why haven’t you tried to ride the subway again?
Client: Because I’m afraid I’ll have another panic attack.
Therapist: How are you handling the fact that your fear of panic attacks is so restrictive?
Client: Not so good. I’ve been getting more and more scared to go out. I’m afraid that soon I’ll be too scared to leave my house.
As you can see from this example, open questions vary in their openness. They don’t uniformly facilitate depth and breadth of talk. Although questions beginning with What or How usually elicit the most elaborate responses from clients, that’s not always the case. More often, what’s important is the way a particular What or How question is phrased. For example, “What time did you get home?” and “How are you feeling?” can be answered very succinctly. The openness of a particular question should be judged primarily by the response it usually elicits.
Questions beginning with Why are unique in that they commonly elicit defensive explanations. Meier and Davis (2020) wrote, “Questions, particularly ‘why’ questions, put clients on the defensive and ask them to explain their behavior” (p. 23). Why questions frequently produce one of two responses. First, as in the preceding example, clients may respond with a form of “Because!” and then explain, sometimes through detailed and intellectual responses, why they’re thinking or acting or feeling in a particular manner. Second, some clients defend themselves with a “Why not?” response. Or, because they feel attacked, they respond confrontationally with “Is there anything wrong with that?” Therapists minimize Why questions because they exacerbate defensiveness and intellectualization and diminish rapport. In contrast, if rapport is good and you want your client to move away from emotions and speculate or intellectualize about something, then a Why question may be appropriate and useful.
Closed Questions
Closed questions usually begin with words such as Do, Does, Did, Is, Was, or Are and can be answered with a yes or no response. They’re useful if you want to solicit specific information. Traditionally, closed questions are used later in the interview, when rapport is established, time is short, and efficient questions and short responses are needed (Morrison, 2007). Questions that begin with Who, Where, or When also tend to direct clients toward talking about specific information; therefore, they should be considered closed questions (see Practice and Reflection 5.1).
Closed questions restrict verbalization and lead clients toward details. They can reduce or control how much clients talk. Restricting verbal output is useful when working with clients who talk excessively. Closed questions are used to clarify behaviors and symptoms and consequently used when conducting diagnostic interviews. (For example, in the preceding example about a panic attack on the New York subway, a diagnostic interviewer might ask, “Did you feel lightheaded or dizzy?” This question would help confirm or disconfirm one symptom possibly linked to panic disorder.). As compared to open questions, closed questions usually feel different to clients.
Sometimes, therapists inadvertently or intentionally transform open questions into closed questions with what’s called a tag query. For example, you might start with, “What was it like for you to confront your father after all these years,” and then tag “was it gratifying?” onto the end.
Transforming open questions into closed questions is fine if you want to limit client elaboration. When asked closed question, clients will likely focus solely on the answer (e.g., whether they felt gratification when confronting their father, as in the preceding example). Clients may or may not elaborate on feelings of fear, relief, resentment, or other thoughts, emotions, and sensations.
If you begin an interview using a nondirective approach, but later change styles to obtain more specific information through closed questions, it’s wise to use role induction to inform your client of your forthcoming shift. You might say,
We have about 15 minutes left, and I have a few things I want to make sure I’ve covered, so I’m going to start asking you more specific questions.
Beginning therapists are usually advised to avoid closed questions because closed questions are frequently interpreted as veiled suggestions. For example:
Client: Ever since my husband came back from active duty, he’s been moody, irritable, and withdrawn. This makes me miss him terribly, even though he’s home. I just want my old husband back.
Therapist: Have you tried telling him how you’re feeling?
We usually boldly tell our students to never ask, “Have you tried. . .” We believe have you questions are advice-giving in disguise. We’re not against advice; we’re just against asking questions that imply clients should have already tried what you’re recommending. In the preceding interaction, the client might think the therapist is suggesting she should open up to her husband about her feelings. Although this may be a reasonable idea, therapists and clients are better served with an open question: “What have you tried to help get your old husband back?” Our advice—which is not disguised in the least—is that when you feel an impulse to ask a “have you” question (and you will), simply stop yourself, and add the word “What” to the beginning to make it an open question. Closed questions are a helpful interviewing tool—as long as they’re used intentionally and in ways consistent with their purpose.
Swing Questions
Swing questions can function as either closed or open questions; they can be answered with yes or no, but they also invite more elaborate discussion of feelings, thoughts, or issues (Shea, 1998). Swing questions usually begin with Could, Would, Can, or Will. For example:
- Could you talk about how it was when you first discovered you were pregnant?
- Would you describe how you think your parents might react to finding out you’re leaving?
- Can you tell me more about that?
- Will you tell me what happened in the argument between you and your daughter last night?
Ivey and colleagues (2023) believe swing questions are the most open of all questions. They note that clients are empowered to decline answering a swing question by saying something like, “No. I’d rather not talk about that.”
For swing questions to work, you should observe two basic rules. First, avoid using swing questions unless rapport has been established. Without rapport, swing questions may backfire and function as a closed question (i.e., the client responds with a shy or resistant yes or no). Second, avoid using swing questions with children and adolescents, especially early in the relationship. This is because children and adolescents often interpret swing questions concretely and respond accordingly (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). For example:
Counselor 1: Would you tell me more about the fights you’ve been having with your classmates?
Young Client 1: No.
Counselor 2: Could you tell me about how you felt when your dad left?
Young Client 2: No.
Counselor 3: Would you like to come back to my office?
Young Client 3: No.
Swing questions with young clients (especially if you don’t have positive rapport) can produce awkward and unhelpful interactions.
Indirect or Implied Questions
Indirect or implied questions usually begin with I wonder or You must or It must (Benjamin, 1987). They’re used when therapists don’t want to directly ask or pressure clients to respond. The following are examples of indirect or implied questions:
- I wonder how you’re feeling about your upcoming wedding.
- I’m wondering about your plans after graduation.
- I’m curious if you’ve given any thought to searching for a job.
- You must have some thoughts or feelings about discovering your child is transgender.
- It must be hard for you to cope with your wife being shipped out to serve overseas.
You can use other indirect sentence stems to gently imply a question or prompt clients to speak about a topic. Common examples include “I’d like to hear about…” and “Tell me about…”
Indirect or implied questions can be useful early in interviews or when approaching delicate topics. Like immediacy, they can contain a supportive self-disclosure of interest. They’re noncoercive, so they may be especially useful as an alternative to direct questions with clients who seem reticent (C. Luke, personal communication, August 7, 2012). When overused, indirect questions can seem sneaky or manipulative; after repeated “I wonder…” and “You must…” probes, clients may start thinking, “And I’m wondering why you don’t just ask me whatever it is you want know!”
Projective or Presuppositional Questions
Projective questions are used to ask clients to imagine particular scenarios and help them identify, explore, and clarify unconscious or unarticulated conflicts, values, thoughts, and feelings (see Case Example 5.5). Solution-focused therapists refer to projective questions as presuppositional questions (Murphy, 2023). These questions typically begin with some form of What if and invite client speculation. Projective questions can trigger mental imagery and prompt clients to explore thoughts, feelings, and behaviors they might have if they were in a particular situation. For example:
- What would you do if you were given one million dollars?
- If you had three wishes, what would you wish for?
- If you needed help or were really frightened, or even if you were just totally out of money and needed some, who would you turn to right now? (J. Sommers-Flanagan & Sommers-Flanagan, 1998, p. 193)
- What if you could go back and change how you acted during that argument (or other significant life event): What would you do differently?
Projective questions are also used to evaluate client values, decision making, and judgment. For example, a therapist can analyze a response to the question “What would you do with one million dollars?” to glimpse client values and self-control. Projective questions are sometimes included as a part of mental status examinations (see Chapter 9 and the Appendix).
CASE EXAMPLE 5.5: PROJECTIVE QUESTIONING TO ELICIT VALUES
Your use of projective questions is limited only by your creativity. John likes to use projective questions to explore relationship dynamics and values. For example, with a 15-year-old male client who had an estranged relationship with his father and was struggling in school, John asked, “If you did really well on a test, who’s the first person you would tell?” The client responded, “My dad.” After hearing this response, John used the fact that the boy continued to value his father’s approval to encourage the boy and his father to meet together for counseling to improve their communication and relationship.
[End of Case Example 5.5]
And . . . here’s a pdf of the Chapter 5 Table describing the different question types.
So-Called “Tough Kids” in Vermont: The PPTs
Hi All,
I’m virtually in Vermont tomorrow doing an all-day-long workshop on working with so-called challenging youth in counseling and psychotherapy. We start at 8am Mountain Time . . . and 10am on the East coast. Here’s the link to register for the workshop for anyone who suddenly has found themselves with a wide open day. The cost is: $195.
https://twinstates.ce21.com/item/tough-kids-cool-counseling-131540
And for those of you attending the workshop (or anyone who’s feeling nosy) here are the generic ppts (without the active video links):
John Sommers-Flanagan 