When In Doubt, Act Like Carl Rogers
Victor Yalom: You and your wife, Rita Sommers-Flanagan, are well known in the field for your work in Clinical Interviewing, and we are delighted to be releasing your
video on this topic concurrently with this interview, but before we get into that, I know you’ve also done work with mandated or otherwise unlikely and unwilling clients. Much that’s written about therapy implicitly assumes that the client is there willingly, but in many settings, clients are overtly coerced into coming by courts or institutions, or they’re strongly nudged into treatment by their parents or spouses. How do you work with these clients?
John Sommers-Flanagan, PhD: A lot of my thinking in this area sprang from the work I did in private practice, primarily with challenging teenagers. As you can imagine, many of them did not want to be in the room with me, so the challenge was, “How do I engage this person?”
I have a vivid memory of a young man who spent 30 minutes just saying, “fuck you” to me. I remember trying to go through every strategy I could think of. But probably the best of all was just to try to be like
Carl Rogers and listen in an accepting way to that particular message over and over again.
VY: Did you literally reflect it back to him like Carl did, verbatim?
JSF: Well, Carl had a case known as, “The Silent Young Man,” where he’s treating this young man who doesn’t want to speak at all, and I think I was trying to channel him in that situation. So I started off by saying things like, “Well, it sounds like all of a sudden you’re pretty angry with me.” And all I got was, “Fuck You.” Then I was saying things like, “It’s clear that there was something I did or said that offended you and I’m not sure what it was.” Then I did a little self-disclosure. After about 15 or 20 minutes, he was still just saying, “fuck you,” but he started singing it to me as 15-year olds might be inclined to do. That went on for 10 minutes and I’m doing my Carl Rogers impersonation, “Well, you sound like you’re not happy, but even though you’re still swearing at me, you’re not angry any more. Now you’re happy and singing it to me.”
What happened next was really interesting. Keep in mind this was not a first session, it was a sixth, maybe seventh session. When he came in the next week, he sat down in the same chair and looked at me. I was anticipating more anger and more resistance, but the first words that he said were, “I’m just wondering, how would you feel if you were to adopt me?” Which was kind of a shocking change, and actually much more difficult than, “fuck you.”
VY: What did you say?
JSF: Well, he said it in this kind of off-handed way, and I just decided at that moment in time that I should try to be genuine and I responded with some disclosure about feeling a little nervous because this was a young man who had a pretty significant history of violence. I said, “I think I would feel pretty nervous about some of the ways that you’ve been with people.” And that launched us into a different discussion.
For me, it sort of captured how important it is to be, as Marsha Linehan might say, “radically accepting of what the client brings into the room.” Or as Rogers would say, “You just kind of work with what you’re getting.” It seemed to help us go deeper and it facilitated exploration and more engagement.
“You sound like a stupid shrink and I punched my last therapist”
VY: So one thing I get from this nice story is the underlying message of really hanging in there with a client, even in an extreme case where they’re coming in and swearing at you perhaps for the whole session or half a session. Really being there and meeting them head on, and being as genuine as you can.
JSF: Absolutely. A more common example is one that I get all the time with some of the difficult young adults I work with now. A 20-year old very recently came into therapy and I said something like, “Welcome to therapy, how can I help you?” And he says, “You sound like a stupid shrink and I punched my last therapist.”
This again captures a lot of the pushing and testing that happens with reluctant clients. I said, “Well, thank you very much for telling me that. I would never want to say anything that would lead you to punch me, so, how about if we decide that if I say anything that makes you want to punch me, you just tell me and I’ll not to say it anymore?”And the kid sat back and said, “Wow. Okay. That’s alright with me.”
VY: How do you conceptualize uncooperative or unwilling clients?
JSF: Well, there are few different dimensions. The first is how they’re referred. They’re often referred by a probation officer or principal, or the parents bring in someone or someone is abusing substances and has been given an ultimatum, or a spouse insists on some kind of counseling and so they come sort of unwillingly into the room.
Then there is the way that their resistance manifests in the room. Sometimes it manifests in silence. “I’m not going to talk to you and you can’t make me.” My standard response to that is what I think people have referred to as a concession where I say, “You are absolutely right. I cannot make you talk about anything in here. I especially can’t make you talk about anything you don’t want to talk about.” With teenagers, I will say that and then I’ll pause and I’ll say, “Well what do you want to talk about?” It’s like they need to posture by saying that they won’t talk, and when I concede that they’re right, that they do have control over themselves, then they tend to respond.
Other times, as I’ve just talked about, resistance is much more aggressive. I remember an older man who said, “We might get in a fight in this meeting.” That’s a much more aggressive kind of resisting the initial contact.
And, lastly, there are some people who resist through externalizing, as in, “the problem is with my school,” or “It’s with my spouse,” “it’s with work,” “it’s with everyone but me.” The challenge then is to listen empathically without getting too frustrated, because if I get frustrated and accuse the person of externalizing, oftentimes it just makes them more defensive. Those are three different categories I can think of off the top of my head: the very silent client, the very aggressive, and the very externalizing client who has a lot of trouble taking any initial responsibility for his or her problems.
VY: So aside from acceptance, empathy, and trying to really be there authentically, what are some other key principals for the therapists working with these kinds of clients?
JSF: I don’t know if you remember Mary Cover Jones, who did some of the early work with John Watson on helping young children desensitize their fears, but she said, “We have two means through which we can help decondition people. One is counter conditioning, where you have some kind of positive stimulus that you pair with the anxiety-provoking stimulus. And the other one is through participant modeling.” She wrote about that in 1924, and it was pretty amazing stuff at the time.
So I have started to reconceptualize people who are resistant to therapy as people who are anxious about the situation. I think, “How do I produce an environment that is going to counter-condition anxiety? What’s in my environment that might help people feel more comfortable and less anxious?” It’s another principal I’m often thinking of in a clinical situation.
VY: I can’t help but note that you’re pleasantly eclectic. You’re combining the epitome of humanism, the person-centered approach of Carl Rogers, with hardcore behaviorism.
JSF: I don’t consider myself a behaviorist, but I also think that if we don’t understand behavioral principals of reinforcement and classical conditioning, we can inadvertently do all the wrong things.
Foundationally, I want to have an office, I want to have a wardrobe, I want to have a way of being with clients that is going to counter-condition any anxiety that the person might feel.
I want to have an office, I want to have a wardrobe, I want to have a way of being with clients that is going to counter-condition any anxiety that the person might feel. Mary Cover Jones used cookies with children, and when I work with teenagers, I absolutely use food. I will have some food, fruit snacks or something nutritional in the room that I can offer, and in some ways I’m thinking absolutely behaviorally at that point. And I’m also thinking relationally—it’s about having a supportive, mutually collaborative relationship. We’re working together.
VY: Can you say a little more what you mean by examples of counter-conditioning anxiety?
JSF: Well, I was just looking through Skype into your space and you have some fabulous artwork. And I think it’s important to have a room that has comforting, pleasant artwork and other kinds of symbols that will help put people at ease. And if you’re working with LGBTQ people, there should be some kind of symbolic communication that you are welcoming those people into your office.
Same thing here in Montana. We work a lot with the Native American population, and it’s really important to have some sensitivity and representation in our office of that sensitivity.
When working with younger clients, the same thing applies. I was supervising a young man who had a 16-year-old boy client who said, “I will never speak to you about anything important in my life, period.” We knew from his referral info that he had been the person to discover his father had hanged himself, so he had some terrible, complex, traumatic grief.
My supervisee said, “What am I going to do?” And I said, “Take the checkers. Take backgammon. Take some games. Take some clay. Take some things into the room. And don’t force him to talk. Just be with him. Play.”
They played for three sessions, just played backgammon. And at the end of the third session, the client looked at the counselor and said, “Well, should we keep seeing each other? Because you said I only needed to come three times.”
And the counselor said, “Yeah, I think we should keep going.”
And the client said, “Well, okay then,” and he pushed the backgammon set aside and starting talking. To me it seemed like a great example of counter-conditioning. They used playing games as the stimulus that was pleasant and non-threatening.
VY: And participant modeling?
JSF: That’s really important, although obviously you can’t really have other people in the room modeling, so the therapist is the model, and is modeling comfort in all things. Comfort when the client says, “I’m feeling suicidal.” Comfort when the client says, “I want to punch you in the nose.” The response is to appreciate those disclosures, instead of being frightened by them. Being frightened by the client’s disclosures is going to feed the anxiety, instead of counter-condition it or instead of modeling, “We can handle this. We can handle this together. It’s best if we do talk about all these things, even the disturbing things that you bring into the room.”
VY: How do you help students, beginning therapists, achieve that? And, how do you balance that portrayal of comfort with authenticity when, in fact, beginning therapists may not feel at all comfortable?
JSF: That’s a great question, and it’s one of the challenges because you want the therapist to be genuine, and yet at the same time you want them to be comfortable. And often those two things are a little bit mutually exclusive.
But I think first of all, information helps. It’s helpful to our trainees and interns and young therapists to really understand and believe that, for example, suicidal ideation is not deviant. It’s not pathology. It’s an expression of distress, and if people don’t tell you about their suicidal ideation, then they are keeping it inside, and they’re not sharing their personal private experience of distress.
I try to do a lot of education around that, whether it’s suicidal or homicidal ideation or trauma or whatever it is that clients might talk about. It’s really important for young therapists to know if they don’t talk about it, we’ll never have a chance to help them with those legitimate, real thoughts and experiences that they’re having.
And the other big piece is practice, practice, practice.
VY: How do you practice these things?
JSF: To give an example, a lot our students initially do suicide assessment interviews, and they’ll say to their role-play client, “Have you thought about hurting yourself?” I’ll interrupt and say, “Okay, now use the word ‘suicide.’” Now say, “Have you thought about killing yourself?” I’m wanting them to get comfortable with the words and to practice using those words so that they aren’t so terribly frightening.
I remember supervising a new student who was conducting an initial assessment, and about half-way through the 30-minute interview, his client says, “I used to have a terrible addiction problem, and one of the things that really has helped me with my recovery is cycling. I’m an avid cycler and it’s really helped me with my drug and alcohol problems.”
At which point, he freezes in panic and says, “So what kind of bike do you have?”
I stopped the tape and said, “Hey, what was going on?” He says, “I was scared, I didn’t want to open things up.”
I said, “Well she did. She opened it up. She shared with you that she had an addiction problem, that she was in recovery, and that she had a method that really is helpful to her. So it would be perfectly natural for you to then use your good active listening skills and ask an open question or do a paraphrase or reflection of feeling, and to stay focused on the target, which was addiction recovery coping, instead of asking what kind of bike she had.”
So it’s a combination of offering encouragement, practice, and feedback.
VY: In addition to behavioral principles and humanist principles, what other theories or principles do you draw from?
JSF: Well, in the psychodynamic realm, I’m thinking of Edward Borden’s work on the working alliance and his effort to generalize it from the psychoanalytic frame to other frames. And the emotional bond between therapist and client, which Anna Freud wrote about initially. We really try to facilitate that.
We also engage in collaborative work toward goal consensus between therapist and client, and it could be that we agree that the therapeutic task involves free association and interpretation and working through. Or it could be a therapeutic task that involves exposure and a real behavior modification approach.
Clinical Interviewing
VY: You and your wife Rita Sommers-Flanagan have written a comprehensive and widely-used textbook entitled, Clinical Interviewing, about the initial stage of therapy, where you’ve examined and broken down in great detail all the aspects that those first few sessions. Can you explain what you mean by “clinical interviewing?”
JSF: It’s a term that originally referred to the initial psychiatric interview, which has a lot of assessment in it. So it refers to that initial contact. But as we have grown, we’ve come to see it as not just an initial contact. In some ways, every contact is a clinical interview in that every contact involves this sort of two-headed goal of assessment and helping. And then the third component is the working alliance, or the therapeutic relationship.
As we know, assessments in a clinical interview produce more valid data if we have a good working or therapeutic relationship. The evidence is very clear that therapy outcomes are more positive if we have a positive emotional bond, and we’re working collaboratively on goals and tasks. So I see the therapeutic relationship as central to the assessment and the helping dimension of the clinical interview.
VY: It’s the beginning phase of therapy.
JSF: Yes.
VY: In reading your text and also in viewing the video we’re releasing conjointly with this interview, you really emphasize the importance of the therapeutic relationship or rapport-building as an integral part of that initial contact.
JSF: Right. Even if you’re doing something as straightforward as a structured diagnostic interview, or a mental status examination, you really want to engage in a therapeutic way with the patient or the client.
VY: Because you’re not going to get much information or accurate information if they don’t feel like you’re on their side?
JSF: Absolutely. It’s about establishing trust and helping people to be open. I’m very familiar with your father’s work, and in The Gift of Therapy, he writes, “In recent and initial interviews, this inquiry into the typical day allowed me to learn of activities I might not otherwise have known for months.
Even if you’re doing something as straightforward as a structured diagnostic interview, or a mental status examination, you really want to engage in a therapeutic way with the patient or the client.
A few hours a day of computer solitaire, three hours a night in Internet sex chat rooms under a different identity, massive procrastination at work, ensuing shame. A daily schedule so demanding that I was exhausted listening to it.”
And he goes on and on about these disclosures that he was able to get by asking a simple question, “Tell me about your usual day.” To me, that’s a great example of how rich the assessment data can be with a simple question, if you have a positive rapport and therapeutic relationship.
VY: So it seems like a fundamental balancing act that you’re always dealing with is how do you balance getting sufficient information—particularly if you work for an agency where forms are a part of the process—while establishing sufficient rapport. Because if they don’t come back for a second session, the treatment is surely a failure.
JSF: Right, how do we balance the information-gathering task that we might have for our agency with the relationship task? And how do we do that with culturally diverse clients?
One of the things we try to do in the Clinical Interviewing book is to go into detail—with an outline and structure—of different kinds of initial clinical interviews, including the intake and the mental status exam, suicide assessment, diagnostic interviewing, and other kinds of interviews, yet emphasizing throughout the importance of the relationship.
So if I have a checklist that my clinic is requiring me to fill out, I would say to the client, “This part of our task today. I am supposed to ask these questions and record your answers, but I also want to hear from you in your own words things that you’re experiencing. So I’ll try to balance that with you.” And I’ll actually show them the questionnaire or the checklist.
VY: So be transparent.
JSF: Be transparent. Absolutely.
Multicultural Competence and Moving Beyond Your Comfort Zone
VY: You mentioned different cultures. What are some particular considerations that come to mind about that?
JSF: Well, some of the principals that come to mind for me involve respect for the native culture here in Montana and throughout the U.S. I think respect is a core part of beginning any relationship. And I think respect involves understanding and being able to pronounce the names of various tribes, asking very gently and respectfully about tribal affiliation here in Montana. I will sometimes say that I know some people from, say, the Crow tribe who have been students in our program. Even if they don’t know the particular students, it can be helpful to hear that I have had contact with somebody who’s got the same tribal affiliation as them.
Cultural competence also means that we take the time to read and study about working with Latino or Latina clients. It also involves using what Stanley Sue referred to as “dynamic sizing” and “scientific mindedness,” where we try to figure out, “Does this cultural generality apply to the specific cultural being in my office?” That’s a difficult but very important thing to determine.
VY: Just a couple weeks ago I had the privilege of interviewing Stanley Sue’s brother, Derald Wing Sue, on multi-cultural issues. One of the things he emphasized was really getting outside of your comfort zone and getting to know these other cultures on a more than superficial level.
JSF: Another thing he really emphasizes is the question that can’t help but be in the back of the mind of many minority clients: “Is this therapist the kind of person who will oppress me in ways that other people in the dominant culture have oppressed me and my family, my tribe, or my culture?”
One of the remedies that he and others have talked about is for therapists to be more transparent, and use a little more self-disclosure. Because without doing that, there’s just no good evidence that we’re not the oppressor or the “downpressor” as some Jamaicans would say.
So diving into the culture, getting to know it on more than a surface level, and then being able to use some of the principals that Stanley and Derald Wing Sue have articulated well is essential. It makes things much more complicated and much more rewarding.
Intake Essentials
VY: There are many models of how that initial client contact occurs—from a brief telephone intake to, in certain settings like substance abuse or mental health treatment centers, having a designated intake worker who passes on the client to interns or therapists. Do you have a general recommendation or sense of what the best practices are for the initial intake?
JSF: Well, in agencies where there is a handoff from an intake worker to other therapists, it can be difficult to maintain the therapeutic connection. In that case the initial session becomes much more about clinical assessment than initiating therapy.
Constance Fischer and Stephen Finn have written about these kinds of therapeutic assessments since at least the late 1970’s, and they suggest complete transparency through the process. “Here’s how things work in this agency.
This will be my only session with you. I would like to work longer with you, but what I’m going to be thinking about during our time together is who might be the best match for you for ongoing counseling or psychotherapy.”
Without that transparency we run the risk of alienating the client—leaving them feeling like, “Oh, man, I have to go through all this again with another person next week?”
VY: It’s hard enough for people to get into treatment in the first place. As I often say to clients, “People are not usually waiting in line to get the therapy.” It often takes people years.
JSF: Right, and when we put another hurdle there it makes it even more difficult. So it’s important to explain the hurdles and let them know how best to get over the next hurdle.
VY: Is your general sense that it’s better not to have a separate person doing the intake if possible?
JSF: I think it’s better to have the same person do the intake and then continue with therapy. There are, of course, exceptions to that. If you have someone who is not well-trained in substance abuse therapy, and then it becomes clear in the first intake session that this person has an active substance abuse problem, transferring the person to a therapist or counselor who has that experience would be a better fit.
And you can just explain that to the client, although oftentimes the client will still say, “Oh, but I’d rather work with you.” But as long as you have a good rationale, you can make that transition relatively easily. So, yes, it’s best to have the same person do the intake and then continue with the therapy, except in situations where there’s a clear rationale to do otherwise.
Treatment Planning
VY: What are your thoughts about treatment planning? There’s a lot of emphasis on that in many agencies. Do you think that’s something that actually can be done with any specificity? So often someone comes in thinking they’re here to work on X, and six weeks later, you’re really working more on Y. So at times I wonder who the treatment planning process is really serving. Is it really serving the client, or is it serving some agency needs, some funding needs, or the anxiety of the therapist?
JSF: I remember an old supervisor saying to a group of us, “We’re not technicians. We can’t really lay out a protocol for exactly how to act with every client. Every client’s unique, so we need to go deeper than that. We’re professionals, and we bring both art and science into the room.”
I think it’s important to blend the two.
I’m not a big fan of cookie cutter treatment plans. But I am a fan of looking at the plan, talking with the client about what our plan is, and being somewhat explicit and collaborative in that process. I see it as a kind of dialectic—it’s a little bit cookie cutter in that it doesn’t bring in much of the individuality of the client but it does have some important information for us. From there we can dive into the unique qualities of the client and their experiences.
As an example, let’s just say you have a client who’s impulsive. We know that there are certain kinds of treatments that we might use with someone who is diagnosed with ADHD who is impulsive, where those impulsive behaviors are getting him or her in trouble. It’s good to know about CBT and other kinds of therapies that might help with impulsivity. But it’s also really important to get into the mind and, in some sense, the body of that individual client to understand what’s going on with that person.
But knowing that there are probably triggers that increase and decrease impulsivity is something you’d want to work on with a CBT treatment plan. It can help focus the questioning, even if you’re working from an existential perspective.
“Evidence-Based” Treatment
VY: As you’re a professor at the University of Montana, and actively involved in training students, I’m wondering what your thoughts are about the major trend towards “evidence-based” treatment? There are a lot of leading figures in the field who are critiquing this trend. John Norcross talks about evidence-based relationships, since research actually shows that most of the positive outcomes in therapy are based on the relationships and not on this or that technique or procedure. Are you pressured by accrediting agencies to teach evidence-based treatments? What have your experiences been in this regard?
JSF: Yes, there is a lot of pressure to incorporate “evidence-based,” or “empirically-supported treatments.” When you look at Norcross’ work, you have to shake your head and wonder why we focus so much on technical procedures and evidence-based treatments. The science just really isn’t there. There are studies done that show X or Y treatment is effective and, therefore, it becomes evidence-based. And yet there’s a mountain of evidence saying otherwise, that it’s not the specific protocols that make a positive treatment outcome.
There are these voices in the wilderness, like Norcross, crying out about this, but there’s still this inexorable trend towards requiring these evidence-based treatments in training students and in various government agencies, for example.
The cynical side of me would say it’s about trying to get our share of the healthcare dollars. Shaping ourselves to be in the medical model, since there are empirically-supported medical treatments. Of course, there is some real scientific evidence that we should be aware of when working with our clients. We should be, because we’re professionals in this area. Like Norcross writes about, there are evidence-based relationship principals that account for positive outcomes and so we need to look at those, and we need to emphasize those more than the technical procedures. There are evidence-based relationship principals that account for positive outcomes and so we need to look at those, and we need to emphasize those more than the technical procedures.
But we shouldn’t ignore all technical procedures because, even Carl Rogers would say, “If the technique arises spontaneously out of a particular place where you are in the counseling process, then it may be appropriate.”
VY: In wrapping up, any advice you would give for students or early career therapists just starting out?
JSF: I think my biggest advice these days is to focus on balance: The balance between the science and the art, the balance between the relationship and assessment and diagnosis. We need some diagnostic information in many real world situations, but we should not try to get that at the risk of damaging the therapeutic relationship. The impulse is for people to go one direction or the other. I was at a workshop one time where a woman referred to people as science “fundamentalists,” which I thought was a very apt description of some people. They have this allegiance to the paradigm of modernist science, and that’s the only way truth is known.
Then there are people who are much more touchy-feely and go with the flow. My general advice would be, if you’re more of a touchy-feely person, you really still need to learn the science. You still need to read the clinical interviewing text and understand the content that is our professional foundation. And if you’re more inclined toward scientific fundamentalism, you need to get out of that box and try to learn from the other side of the dialectic, which is the relational, emotional side of things that happen in the therapy office.
Advice for the Late-Career Therapist
VY: So let’s use mid- or later-career therapists as an example. By that time in their careers, many have migrated to private practice and have gotten very comfortable in their own ways of being with clients. In many ways that’s a good thing—it’s part of the career progression to take everything you’ve learned along the way and integrate that into who you are as a person. But one drawback I see is the possibility of just jumping into therapy with any client who walks in your office—assuming they’re a good fit for you—without maybe doing a proper assessment. And then they find out six months down the road that the client has a drinking issue that they hadn’t disclosed before. Any advice for these later-career therapists?
JSF: Yes. I’m not in full-time private practice right now but I have friends who see 35 people a week, and are doing the kind of thing you’re talking about.
It’s so easy for us to get into a little niche where we do it our way, and we’re no longer open to other ways of thinking. I’d say it’s really important to keep stretching yourself, to keep reading, to keep going to professional workshops, because we can do things wrong for years and think that we’re actually being successful.
Scott Miller is emphasizing it now more than anyone else–but it’s incredibly important to get systematic feedback from our clients so that we can get a sense whether we’re on the right track with each individual client.
Even though we sometimes can convince ourselves that we’re incredibly intuitive and we can, therefore, launch into therapy immediately, there is some research that suggests that negative outcomes correlate with inadequate assessment. So we do need to step back and do a little formal assessment here and there, even though, as experienced practitioners, we might think, “I know what to do here. This is not a problem.”
Instead, step back and to say, “Let’s do a little bit of assessment here so we can work together to make sure that we’re on the right track.” In other words, mid-therapy adjustments and assessments to make sure that we are helping our clients as effectively as possible.
VY: A final question: What’s your growing edge right now as a teacher and practitioner?
JSF: I have several growing edges. One growing edge that’s pretty constant for me is working toward greater cultural sensitivity, and being able to know more deeply about people who come from diverse minority kinds of backgrounds.
Another growing edge for me is the whole idea of mindfulness and how to incorporate that into some of the more traditional ways that I was taught to do psychotherapy.
I think the other growing edge for me is kind of a growing foundation. The person-centered principals for me have always been foundational and I find myself sometimes really wanting to go back to those. I can see myself in future months or years going to some trainings to get even better at the things that I think are my basic foundational skills.
VY: I often have the opportunity to review some old videos that we’ve acquired or produced and just recently watched the first video produced with
James Bugental, a human-centered existential therapist. I’ve probably seen that video 20 times and I still appreciate it, perhaps on an even deeper level.Well, I want to thank you for taking the time to talk with us today.
JSF: Thank you very much, Victor. I very much appreciate your work and the fact that you have dedicated a lot of your life to making the work of other great therapists accessible to all of us.
