Tag Archives: Psychotherapy

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

The One-Way Mirror Project and Self-Reflection: A Process of Pain and Growth

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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

  1. 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.
  2. 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.
  3. 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.  
  4. 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.
  5. 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.
  6. Evelyn’s Goal – 1:50 – Evelyn says she wants a “different perspective” of what she’s worried about.
  7. 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.”
  8. What I Know – 2:25 – This is another effort to be like Carl Rogers and show transparency.
  9. 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.
  10. A Broad Summary/Paraphrase – I respond with an accurate summary of her four “feelings and thoughts”
  11. “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.
  12. 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
  13. 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
  14. 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.
  15. 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?”
  16. 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.
  17. 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.”
  18. As a Good Therapist – 15:35 – Evelyn expresses motivation to be a good therapist and that requires expansive live experiences.
  19. 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]
  20. I Reflect – 18:30 – Being a better therapist and fear of death motivate her to live a life full of experiences.
  21. 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
  22. Values vs. Anxieties – 19:55 – Still feel anxieties. “I have to carry a child” etc. . . walking within. Amplifying expectations so she can hear them.
  23. That’s my barrier –
  24. 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. . .
  25. 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]
  26. 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?”].
  27. 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.
  28. 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]
  29. 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.
  30. 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.
  31. 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.]
  32. 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.]
  33. 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.
  34. 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.”
  35. 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.
  36. 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.
  37. 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.
  38. 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.
  39. Closing – 56:40 – Awkward. Not smooth. Not good.

Clinical Interviewing, Suicide Assessment and Intervention

The Handout for this Friday’s Strengths-Based Suicide Workshop

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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.

Traditional and SB Assessment for CBI 2025Download

You may recall that this workshop is ALMOST FREE. Only $25. There’s still time to register here:

https://cbicenterforeducation.com/courses/strategies-for-integrating-traditional-and-strengths-based-approaches-to-suicide-january-2025

I hope to see you there!

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

Questions (and Mindfulness) in Counseling and Psychotherapy

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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).

**************************************

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.

Question TableDownload
Cool Counseling, Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

So-Called “Tough Kids” in Vermont: The PPTs

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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):

Vermont 2024 TKCC WorkshopDownload

Cool Counseling, Therapy with Adolescents, Tough Kids

Tough Kids, Cool Counseling — An Online Workshop – Dec 6, 2024

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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.

Clinical Interviewing, Writing

Cultural Self-Awareness in the Clinical Interview

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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:

  1. Be open to exploring your own cultural identity. Gaining greater awareness of your ethnicity is useful.
  2. 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).
  3. 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).

[End of Case Example 1.2]

Clinical Interviewing, Writing

Culture-Specific Expertise in Clinical Interviewing

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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.

Clinical Interviewing, Writing

Clinical Interviewing – 7th Edition: Video Resources

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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.

The other good news–and possibly the best news–is that these videos are now available online, for free. Although we want you to buy or adopt the Clinical Interviewing textbook for your classes or professional development, you can access these videos without adopting or purchasing the book. Here’s the link: https://higheredbcs.wiley.com/legacy/college/sommers-flanagan/1119981980/vids/9781119981985_Videos.html?newwindow=true

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.

Have a fantastic evening.

John S-F

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Group counseling, Group therapy

The Power of Language

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

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

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

First, we say, John behaves nervously.

Later, it becomes, John is nervous or anxious.

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

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

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

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

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

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

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

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

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Using Bias-Free Language

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

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

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

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

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

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Group counseling, Group therapy

Group Leadership: Talking More and Talking Less

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Teaching Group: Talking More and Talking Less

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:

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