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Reid Wilson on Strategic Treatment of Anxiety Disorders

Posted on September 21, 2012March 13, 2026 by rezendevknowfully.com

What is Anxiety?

Victor Yalom: So, Reid—good to be here with you. I guess a good place to start would be to define what anxiety is and how you distinguish between normal, healthy anxiety and irrational or counterproductive anxiety?

Reid Wilson: Well, that’s a broad question. We’re programmed to be anxious when we feel threatened—whether it’s an immediate threat or a distal threat—so anxiety disorders break down, in some ways, like that. Someone with panic disorder is threatened by an immediate danger; someone with generalized anxiety disorder tends to worry about things coming far in the future. We define people who have anxiety disorders, loosely, as those who have irrational fears of those kinds of threats.But the body responds impeccably to false messages. That’s part of the trouble of trying to help people get better—so much of the anxiety disorder symptoms have to do with naturally occurring responses to a perceived threat. So in many ways, as we do the treatment, we work against nature for a while until we can bring someone into balance.

VY: Before we get into treatment, let me try and understand that a little better. Anxiety is a natural mechanism to protect us against threats, but when it becomes counterproductive, or when our sensation of anxiety doesn’t match what’s going on in our environment, it becomes a disorder.

RW: Right.

VY: And the range of anxiety disorders is quite diverse, right? You have general anxiety disorder, panic attacks, specific phobias, OCD, PTSD. Is there a commonality among those? Is it useful to think of those together, or are there things that are quite discrete?

RW: I think that the most difficult one to sort out is post-traumatic stress disorder and there’s a tremendous number of researchers who are trying to figure out what the common denominators are within post-traumatic stress disorder. With the other disorders, there is a great deal of commonality. People with anxiety disorders have an intolerance of uncertainty and distress, and much of what we need to address in treatment is about resistance—about all the fighting and pushing away of symptoms that people with anxiety disorders use to stay out of discomfort. It’s not so much that someone’s having uncomfortable symptoms, it’s their response to their symptoms. Their tendency is to go, “This is terrible. I can’t handle this. I need to escape,” and we need to change that response.What varies is the contribution of genetics. Obsessive-compulsive disorder is almost completely genetic, whereas someone with a specific phobia of animals can have little or no genetic influences and be much more influenced by traumatic experiences or environmental factors.

In terms of how people respond, there’s a lot of commonality as well. That’s why part of what I’ve been trying to work on over the years is how to peel away all these innovations and exercises and structures that we use for people with anxiety disorders down to the lowest common denominator.

VY: I’ve seen you work with clients, and this idea about changing their response to their symptoms seems to be a core of your approach, but it’s kind of counterintuitive to clients as well the therapist. Can you say a little bit more about that?

RW: Sure, but it’s not like I have invented a system that hasn’t been around for a while. If we look at what’s been going on with mindfulness approaches to treatment, some of the work that’s been done in Buddhism for a couple of thousand years has to do with stepping back and observing the present moment, not reacting to it personally, and not taking the events to heart, as most people do. Part of what I have been trying explore is how you get people from point A to point B as efficiently as possible.

From Resistance to Detachment

VY: And what’s point A? What’s point B?

RW: Point A is what we’ve been speaking of, which is the resistance, the fighting, the trying to get away—“It’s bad or wrong that I’m experiencing this.” Point B is detachment. When people resist their experience of anxiety or panic, there is a significant amount of psychic energy invested in that resisting. When working with people, I try to respect the degree of energy that’s going into the fight.To expect our clients to move from the intense energy of resistance all the way to detachment is too grand an expectation. That’s why we have a lot of trouble keeping people in treatment, or even having people begin the treatment to start with. When you’re shopping around for help with your anxiety, what you hear is, “You’re going to have to do exposure over a number of weeks or maybe months. You’re going to have to go toward these terribly uncomfortable feelings and sit with them for a length of time, and then you will begin to notice a change.” But people who suffer from anxiety disorders are concerned with the immediate moment. Everything gets very tight for them. Their concern is, “but what do I do right now?” That’s what I want to present to people.

VY: Just so I understand, when you talk about resistance and all the energy that goes into resisting, how would this work with panic disorders? Is it that lot of time and discomfort is about anticipating and fearing the panic attack rather than the panic attack itself?

RW: Certainly. A panic attack, which lasts for 30 seconds—actually that is a relatively long panic attack—is less than .1 percent of the day, but people will focus the entire day on trying to prevent themselves from experiencing another panic attack. Somebody with obsessive-compulsive disorder may only wash their hands for 25 minutes a day, or check the doors and locks and windows for a half hour a day, but when you ask them how long they spend obsessing, they might say, “eight hours.” It’s very consuming psychically. All that bracing is the energy that needs to be redirected toward getting better.

VY: So how do you get from A to B?

RW: I attempt to honor and respect the energy of the resistance and help clients use that energy in a different way. The opposite of being frightened and bracing against a sensation or a pending dangerous experience is to let go. But letting go doesn’t represent a change in the emotional state. I believe we need to maintain the degree of emotion—so the opposite of terror is, to some degree, excitement or desire.In other words, we’re going to move toward that which we fear with a sense of zeal. It really gets crazy. It’s already paradoxical to move toward it and here we’re doubling down. It’s not, “Oh what I need to do is face my fear, therefore I’m going to step into that crowded elevator”; it’s, “I’m seeking out that state that I’ve been afraid of.”

Exposure Plus

VY: So that’s what you mean by “strategic therapy” or “paradoxical therapy”—encouraging people to go towards their fears with a kind of relish?

RW:

Strategic therapy is messing with patterns. So we’re going to find the pattern, and then mess with it.

Strategic therapy is messing with patterns. So we’re going to find the pattern, and then mess with it. Telling people to go toward what they fear is exposure, but we’re trying to do exposure plus. Go toward it and change my emotional state to, “I want this feeling. I want this experience.” But we need to be clear about what we are asking people to seek out. People with anxiety disorders have an intolerance of uncertainty and distress, so what they need to seek out is not that crowded elevator, not that battery they perceive is contaminated, but the generic sense of uncertainty and distress.

That’s a really the hard sell for people because it requires them to separate from the content of their worries and invite in more generic uncertainty and distress. And then the frame becomes, “I want to get better. I want to be with my family again. I want to be able to take the job on the 23rd floor. I want to fly to my cousin’s wedding in three months.”

Habituation is a fundamental element of exposure therapy and we know from the research that it takes three variables to get fully habituated and get better: frequency, intensity and duration. So if they want to get better they need to have enough distress, frequently enough and for long enough to make this practice count.

But I want to teach them the most generic way to do this as possible, because what we know is that anxiety disorders run the life cycle. Somebody can finish treatment with us and be doing great and be down to “normal” in terms of anxiety, and then three years later have a whole other brush with either the same disorder or another anxiety disorder. So we want to train people in a protocol that they can brush off again and start using if and when they encounter the disorder again.

The Art of Persuasion

VY: How do you propose this to your clients in the first place, and how do you get them to that state of wanting to go towards their fear?

RW: Persuasively. That’s my job—to find any and every mechanism to help change their mind. So I’m going to work at the level of frame of reference and I’ll use examples of other patients. I’ll use metaphors, I’ll give analogies, I’ll use logic, whatever I can use. I told a woman the other day, “If your son were in fifth grade and had to play the guitar every night, you could imagine him going, ‘Darn, I have to practice now.’ But if he sat down with his high-school cousin who plays in a rock band, and saw how cool it was, this fifth grader would begin to want to practice guitar every night. You can imagine the difference between a fifth grader having to practice for an hour, and a fifth grader wanting to practice for an hour.” That is the kind of shift I’m seeking for my clients and I’ll use these kinds of analogies to help them understand it on a deeper level. Every angle I can find to start loosening up their rigidity and resistance.

VY: We recently filmed you treating two clients for a new video series on Strategic Treatment of Anxiety Disorders that we’re releasing along with this interview, and one thing I noticed about you is you really take charge. You’re very directive. You tell the clients what to do. You tell them what may happen.It’s very different than a lot of therapists are trained. I think whether we’re trained from a more client-centered or psychodynamic point of view, that legacy of therapists being somewhat passive and letting the client lead the way has seeped into so much of our training as therapists. I’m wondering if you’ve observed that therapists have a hard time with taking charge in the way that you do.

RW: I would challenge what you’re saying because, yes, I’m dogmatic and I boss people around and I can be very dominant. On the other hand, I also try to come across one-down in certain situations.

Yes, I’m dogmatic and I boss people around, but I also try to come across one-down in certain situations.

“I’m not sure about what I’m saying right now, but what do you think?” I turn back to them to find out whether they’re starting to understand what I’m saying. I give them a protocol but say, “It’s an experiment. Let’s gather information about it.” There is a balance between coming on very strongly to somebody and, at the same time, accessing a sense of curiosity.

When I train therapists to do this, it’s somewhat intimidating to them and counter to how they have learned to do treatment. But we’re also talking about therapists who come in to get trained because the patients or clients that they see are pretty tough nuts to crack and they need some therapeutic leverage to help people move along. So I think they are also receptive to the ideas.

VY: One client that we see you working with in Exposure Therapy for Phobias, presents with a fear of flying, which, upon exploration with her, you narrow down to claustrophobia—a fear of enclosed spaces and suffocation, not being able to breathe. You do classic exposure therapy with her—which I had heard and read about but never seen in action—where you actually put a nose clip on her, put a pillowcase on her head and wrap that pillowcase with tape. Later you get her to go inside an enclosed box. That requires, first of all, that therapists get out of their cozy chairs and stand up and move around. That’s something that many therapists have no experience doing.

RW: Sure, it’s a big step but people are relatively motivated because we have a certain percentage of people with anxiety disorders that have very rigid belief systems. If you don’t find a way to start cracking that belief system open, it’s very frustrating for you as a therapist.

Chasing the Anxiety Boogeyman

VY: So give us a sense of how this works over time. I get the general principals, but how does it actually play out over sessions?

RW: Well, I work at the level of principles so I am not technique-focused, and that already makes me a little different than other CBT therapists. I don’t start with, “Here’s how you get better.” I start at the level of, “Here’s how I perceive what’s going on now for you. Help me understand. You know yourself—let’s see if we’ve got a match here.”

Psychoeducation is a big part what I do, particularly around the physiological and neurological aspects of these disorders. I talk about the neurology of fear and what happens with the amygdala when we are scaring ourselves. It’s important for everyone to understand this aspect, which has to do with bringing the amygdala into the threatening situation and letting it just sit there and experience the situation and discover that it’s secreting too much epinephrine. We do that by quieting the prefrontal cortex. We need to stop scaring our amygdalas so that we can be present in the elevator, in the grocery store, with our heart rate accelerated, and discover that it doesn’t need to make me us excited.

A lot of the crazy kind of talking we engage in has to do with refocusing the attention of the prefrontal cortex so that it doesn’t keep continually saying, “Uh oh.” We’re trying to override that message with an executive voice that says, “I can handle this. Let’s go toward this.” So we need that in place.

And then we’re sending people out with experiments to do in which they notice those thoughts popping up or have that sensation in their body that’s been scaring them and then step back enough to go, “It’s happening—it’s okay this is happening,” and then transform it to, “I want this. Give me more.”

My orientation is a set of principles founded on the notion that content is irrelevant. That’s the first step that I need to get across to everyone. Then I personify the anxiety disorder to help them detach from the content of their worries. I’ll say something like, “The anxiety disorder hooks you by picking a topic that is personal to you. That’s how it creates doubt and resistance in you.”

So, for example, if you’re a single mother with three kids and have just lost your job and are not sure how you’re going to pay the rent in two months, that’s very stressful for you and it certainly is going to cause you to worry. But if you develop a sub-routine of worrying throughout the day about it, there’s no redeeming value in that process. So in your case I’ll say, “the anxiety disorder picks the fact that you’re going to have a hard time paying your rent and taking care of your kids. That’s a topic that’s threatening to you as a parent with young children.”

VY: But why do you personify? Why do you say, “it picks?” Do you actually believe that, or is that a tool that’s helpful?

RW: Do I actually believe that? What we’re trying to do is put into language something that’s unconscious, so I believe not so much that as—

VY: There’s no an anxiety boogeyman out there trying to get us, right?

RW: Well, maybe. What I believe is that to perceive it in that manner is therapeutic. It is a way to begin to get a sense of what’s going on. That’s what I want to do—help clients get ownership in comprehending the disorder. What is the nature of the disorder? Why is it running me? In many ways, I’m unconscious of the game that’s being played on me, so I want to bring that up to consciousness.

VY: Alright. So going back to the example of the single mother and her worrying throughout the day, what do you do with that?

RW: First off is to distinguish the content. If I don’t distinguish the content from the process, she’s going to think I’m crazy, because she should be worried. So first we isolate out worries that are signals: “I need to go find another job and I need to go to the government to see if they can help me for this period of time”—these are worries that she actually has a responsibility for and can take some action on, and now is the right time to take action. That would be the definition of a worry that is a signal, and we’re not working on those so much, though we certainly have to problem-solve.

VY: That’s what you would call normal or adaptive anxiety.

RW: Right, exactly. We’re separating that out. We do need to do problem-solving. If I can help you with that, then I’m going to work with you on that too. But on the other side is the worry that is just noise—repetitious, unproductive thinking that causes distress. That’s the content that is irrelevant and that’s what we want to isolate. So we’ve got the circumstances of your life, and then we’ve got how the anxiety disorder has come in and taken hold of that.Another example: If you’re afraid to fly, I’m going to try to teach you interventions to relax on the plane; but if you think the bolts are going to fall off the wings, there’s nothing I’m going to do to help you be comfortable. That would be inappropriate.

If instead we can change the story and get somebody who has a fear of flying to understand that the discomfort they’re feeling is inside them, is their responsibility—it’s not about the pilot or bad mechanics—then perfect. That’s what I want. People come in with a list of 15 things they don’t like about flying, but if they can say, “basically it comes down to feeling out of control,” we’re in business. That’s a theme of all anxiety disorders that we want them to understand.

The second piece is coming to accept their obsessive thoughts. Whether it’s, “when can I pay my bills?” or “was that battery contaminated?” their job is to accept them, to be fine with them. That can seem like a crazy intervention for people because we don’t go the route of reassurance around content. Instead we’re asking them to say: “It’s fine. That thought popped up because I have an anxiety disorder. That’s what we do. We generate thoughts that freak us out. And so instead of freaking out about it, when it shows up, I’m going to accept it.”

In order to get to the place of acceptance, we’re going to play some kooky games, like, “Give me your best shot” and “I’m not worried enough—make me more worried.”

The Anxiety Game

VY: You use the term “games” a lot. What do you mean by games?

RW: Perceiving the disorder as a mental game. Personifying the disorder. When I have an obsessive thought or an anticipatory worry or dread that I know is noise, I want to step back and notice it. That, in itself, is an intervention: “Oh, I’m worrying again. Oh, there’s that thought.” Now the next thing I am asking people to do, if they’re going to play the game vigorously, is to ask the disorder to increase those reactions that they’re having.So, for example, if I’m having a worry about not being able to pay the rent at the end of the month and that’s scaring the bejeezus out of me, I’m going to step back and notice it, acknowledge I’m feeling afraid about it, and request that the anxiety disorder increase my worry: “Please give me another fearful thought. That really scares me, but not quite enough.” So I’m always turning to the disorder and requesting it increase what it just gave me.

Viktor Frankl was the first person to write about paradoxical intention, and how he framed it was: Look for your predominant uncomfortable sensation and ask that sensation to increase.

VY: This is what was referred to as “paradoxical therapy.”

RW: “Paradoxical intention” was what Frankl wrote about in Logotherapy. And I did that for 20 years or so, but about 10 years ago I made a little switch—from asking my heart to beat faster to asking panic disorder to make my heart beat faster.That does an interesting thing which is, “I’m no longer responsible for increasing my heart rate. The panic disorder is responsible for it. I can now turn my attention back to my task of the moment.” Now, when you’re really anxious, you’re not going to get very far away from your fear; your obsession may show up again in eight seconds. But my position is to return to that request—”Please make my heart beat faster.”

VY: It sounds kind of ludicrous.

RW: It’s absurd.

VY: Right.

RW: And that’s what we’re looking for.

VY: And how do clients respond to that, typically?

RW: Well, as long as I have them long enough. If they heard me in a lecture hall, they might walk away shaking their head, but if I have enough time with them, they can see what it’s like. We go through it for a while and, if I can convey it to them well enough and convince them to try it out, in low-grade experiences where they’re not highly threatened, they can experience themselves getting better. Experience is the greatest teacher. That’s why I want to convince them to experiment with it to one degree or another.You really have three choices: Resist, permit or provoke. And I think much of the treatment of anxiety disorders over the last years has been to “permit” symptoms, to “allow” myself to be anxious. Allow things to sit there inside me. Allow the worries to show up. But that’s where people are going to finish the work; it’s not where I think people should begin the work—which is to provoke that which they’re afraid of.

VY: I had the pleasure of getting to know you a bit making these videos with you and I must say you’re a funny guy. When you do these paradoxical interventions, there’s a humorous side to it that fits with your personality. But does that work for everyone? Can therapists who have more sober personalities find a way to play with this?

RW: I don’t know how much humor is required in these protocols, but it’s a resource that I have and we use what we have. The most important thing, I think, is the resource of making contact and getting rapport with people and you can do that from the very beginning; and then it’s trying to access curiosity. I don’t think you have to have humor in order to authentically invest in being curious about, “What will this do for you if you try this out?” You know, I do talk about principles, but this is psychotherapy and it takes some finesse to help someone. I think people who have a lot of training in psychotherapy know how to do some of that stuff.

VY: I know it’s very hard to make generalities in therapy, but do you have a typical length of treatment for certain types of disorders?

RW: We typically have a 12-session intervention for people with panic disorder but we’ve got new data published that they’ve brought it down to five sessions. If we can unbundle what we’ve been doing and go to that lowest common denominator for intervention, we can shorten things up. It takes longer with Axis II disorders because those are woven into the fabric of the personality, so even though we can create a protocol, and they can use that protocol, it may take months for them to finish off that work for themselves, versus somebody with panic disorder who, in a very brief period of time, can be up like a phoenix.The interesting research that’s being done now is on ultra-brief treatment of panic disorder—even of post traumatic stress disorder—where they have been able to put a protocol in place successfully in five sessions with somebody with PTSD, which seems pretty remarkable to me.

VY: But many therapists, whether they’re in private practice or some kind of agency or other setting, tend to see clients that are a mixed bag. They come in for relationship problems or work issues or some anxiety and depression and, whether they’re Axis II or just have general life problems, their anxiety disorder is only a part of the clinical picture. How do you use these techniques within the context of a longer-term therapy?

RW: When I do presentations for therapists who are treating clients with anxiety disorders—whether they have other comorbid disorders or not—I try to get them to think about how they can structure their sessions in such a way that clients leave each session looking for an opportunity to experience some degree of uncertainty and distress regarding the themes of their anxiety.That’s a pretty simple protocol for the therapist. It doesn’t take a rocket scientist to figure out how to do this work—look at me. It’s a difficult treatment, but it’s not a complex treatment

VY: What makes it difficult for therapists? What’s hard to learn about this?

RW: It’s difficult because you’re looking at somebody who’s been entrenched in their way of solving the problem for a long time. You’ve got a client who does not tolerate not knowing how things are going to turn out. You’ve got a client who, as they try to experiment with something you’re suggesting, must trust you and trust the protocol without knowing how it’s going to turn out.That is the difficulty, because the disorder doesn’t allow them to feel confident. And if you listen to clients when you talk to them as they’re intently trying to learn what you have to give to them, they’re looking for security in what you offer them. “I’ll be glad to do what you tell me to do as long as you’ll give me a 100 percent guarantee I’ll have zero symptoms ever again.” And that’s not going to work. Einstein said: ““You cannot solve a problem from the same consciousness that created it. You must learn to see the world anew.” That’s the thread that runs through all of the treatment.

VY: I would imagine it’s also hard for therapists because they’re natural caretakers, they’re empathic, they want their clients to feel better…

RW: We do have this tendency in our field to keep rapport and be gentle, to not get people too upset. I think a lot of people gravitate to the treatment of anxiety disorders because they have an affinity to that arena. They know what it’s like to be anxious, they may have anxiety problems themselves, they’ve figured out some techniques and want to help others with it. But this is a contact sport. It’s aggressive. It works better when you’ve got a therapist who is already a risk taker.

This is a contact sport. It’s aggressive. It works better when you’ve got a therapist who is already a risk taker.

It’s like the primary care physician who’s trying to help you decelerate from a benzodiazepine that you’re dependent on. When they’re really kind and gentle with you, it sometimes takes forever to get off of them. When they’re a little tougher with you and push, then sometimes it works out better for you.

VY: So you need to be comfortable pushing a client into discomfort.

RW: That’s right.

The Meaning of Anxiety

VY: Existentialists such as Rollo May, who wrote the classic text, The Meaning of Anxiety, and other existentially-oriented psychotherapists would and have argued that there’s meaning in anxiety and we can learn about ourselves, about life, have insight, by delving into it—that it’s not something that should be brushed aside. Do you think that there’s meaning in anxiety?

RW: Well it’s fine to look at it that way, and on an individual-to-individual basis you may have to delve into that. But it does not mean that someone has to continue to express their anxiety in such a primitive fashion. People with panic disorder are expressing conflict very primitively. I certainly believe with panic disorder—and I’ve written about this—that there are benevolent purposes of the symptoms. And to look at those and understand those are helpful, but once we understand them, let’s negotiate another way to get those needs met.

VY: What are the benevolent purposes of the symptoms of panic disorder?

RW: It’s often to keep from being abandoned. There’s some data that a certain percentage of people with panic disorder suffered early childhood loss. Let’s say my father died when I was four, and my mother got severely depressed and laid on the couch every day. There are a lot of ways that I would have learned to cope as a child with that kind of loss. As I grow up, that stuff, existentially, kind of becomes who I am in the world. If my mother turns away from me because my dad left or my father left and never talked to me about why he left, I begin to think that I am not worthy as a human being. What parent, who loves his child, would abandon his child? There must be something inherently wrong with me. Some people with panic disorder use it unconsciously to maintain relationships so that their partner, their parent, whoever, won’t abandon them. That’s a benevolent purpose.

VY: So there’s secondary gain in that.

RW: That’s kind of a derogatory term, but it’s something like that. If we can step back and look at how the unconscious might have stepped in to take care of me, based on my belief about who I am from long ago, then there is a benevolent purpose behind why it showed up.I had a patient who came to me with OCD. She had two children with a workaholic physician who didn’t help with the kids at all. Her biological clock was ticking. She wanted to have another baby, but was concerned about her ability to take care of three kids instead of two. One day, she saw her son chasing her daughter with a kitchen knife and instantly she developed obsessive-compulsive disorder. She couldn’t stop thinking, “Oh my God. Could I hurt someone with a kitchen knife?” She had to get rid of all the knives in the house, everything sharp, all the scissors; no children could come over and be in her home for fear she would harm them. And of course, she was then too sick to have another baby.

So that’s another example of a benevolent purpose of the disorder. I think we do want to look around for some of those things and begin to take care of those, too. If the unconscious is driving some of this stuff that we aren’t aware of, then we’re going to have trouble helping people get better. The other definition of “strategic treatment” is doing whatever is necessary to help somebody get better. So if we need to do some family therapy or psychodynamic work or couples work or Sullivanian work—whatever it takes to help them turn the corner.

VY: It’s nice that there are cognitive-behaviorists who acknowledge unconscious psychodynamics. You’re very integrated. It seems like you really strive to hone in on what works.

RW: I hope that’s true. We just got some new data that suggest that that can help people more rapidly change their relationship with the disorder. We just did a study of people with obsessive-compulsive disorder going through this protocol, 80 people at a time, for two days. And the changes that took place were pretty remarkable, in terms of the measurements of the reduction of their obsessive-compulsive disorder and in altering their beliefs.If you just think about OCD being one standard deviation beyond the mean, where people get so totally caught up in obsessions and rigid belief systems, it’s quite amazing that we can bring about lasting change after only a few days.

Getting to “Aha”

Some folks have done some interesting research on what we called “applied relaxation,” which is learning relaxation skills and applying them to a variety of situations. In six sessions of an hour and a half each, then another six sessions of 45 minutes each, with practice homework throughout that time period, the major thing that these people changed after all this work was their beliefs.

If that’s true, then

I think we should be leading with belief change instead of leading with interventions that require a great deal of time to give someone insight and then for them to go, “Aha.”

I think we should be leading with belief change instead of leading with interventions that require a great deal of time to give someone insight and then for them to go, “Aha.” That’s how exposure and response prevention happens. We’re going to run them through this protocol until weeks or months later they go, “Oh, I see now. I don’t have to do my compulsion to get rid of my obsession.” Can we speed that up? I think we can.

VY: Final question. What advice would you give for students or early career therapists treating this population? Any pearls of wisdom?

RW: Look for any way to sit in on someone doing treatment with someone using these kinds of protocols. See how this works. That’s part of our motivation to get these anxiety disorder videos out there, so that people can immerse themselves moment-by-moment in this protocol. Whenever I do a workshop to teach these skills for therapists, it would be totally and completely fine for clients to be sitting in on the workshop as well because they can understand it just as easily.When I was in training and working with couples or borderline personalities for the first time, I’d go into supervision and say, “Okay. She said this. Now what do I say?” And he would help me figure that out. And then I would say, “Yeah but what if she responds like this? Then what do I say?” It can be daunting if you’ve not done this and observed it directly.

VY: Well I have always felt that we are a strange profession. You wouldn’t have dental students read about doing a filling and then send them off to do it without watching someone and then come back a week later to meet with a supervisor in a closed room and try to recall how they did their fillings. In fact, that was one of the reasons I started making training videos in the first place.I’m grateful that you consented to have your sessions recorded and I’m excited to release them and make them available for people who want to learn about the innovative approaches that you developed. So thank you so much for taking the time to go into this level of detail.

RW: Well, thank you as well for giving me the opportunity.

Emotional Healing Through Creativity (Or: How Creativity Got a Bad Name and What We Can Do About It)

Posted on August 28, 2012February 11, 2026 by Psychotherapy.net Team

As a therapist and theatre instructor, I hear many stories about creativity. It usually goes something like this: Creativity is something you either have or don’t have, and if you have it, you’re probably manic, anxious and neurotic. Certainly, very few clients come to me complaining that they don’t have enough creativity in their lives. However, I’ve come to experience that healthy creativity (and yes, I believe that this exists!) can help in the process of emotional healing.

For the past several years, I’ve hosted an internet radio show about creativity and healing, and this has deeply informed my therapy practice. The stories that my guests have shared go against the narrative that creativity is associated with madness and neuroticism. One guest who continues to inspire me is Ray Johnston, and I’ll share his story to illustrate the power of creativity.

Ray Johnston grew up with one dream: to play professional basketball. However, he went to a small college, was not drafted or even scouted by an NBA team, and eventually graduated from college and found himself working in real estate. However, Ray was living in the Dallas area, and would get tickets to see the Dallas Mavericks. As he began attending games as a fan, he started connecting with former NBA athletes, who encouraged Ray to try out for the Dallas Mavericks summer league. Ray did try out and was eventually chosen to be on the summer league.

If that were the end of the story, it would be remarkable enough, but that’s not where the story ends. Soon after being chosen to play on the summer league, Ray was playing a pickup game of basketball with some friends and banged his shin. The next morning, Ray woke up and his shin was swollen to twice its normal size. Ray went to the hospital and as he recalls, “It was July 2004, and I passed out in the emergency room. When I woke up, I was in a hospital bed and George Bush had just beaten John Kerry for the Presidency of the United States.”

Ray was horrified when he learned that he had been in a coma due to leukemia. He was even more horrified to learn that seven of his toes had been amputated and that he would never play basketball ever again. Ray fell into a deep depression, and wondered what he would do now that his only dream had been taking away from him. Ray could have stayed in that depression, but as he lay in his hospital bed, he decided that he was going to create a new life for himself, given his new circumstances and conditions. Ray decided that he was going to pursue his only other passion—music—and decided to start a band. His doctors and friends told Ray that the stress of creating a band and touring would be too much for his body, and they urged him to stay home and rest.

But Ray did not stay home. He went out and started a band, created music and began touring. As he did this, his depression began to lift. Ray felt like he had a new purpose and mission in his life. He began donating a portion of his proceeds towards leukemia research. And much to the dismay of his doctors, he is still very much alive and touring with his band, the Ray Johnston Band, and working towards his dream of playing in the Dallas American Airlines Center. He has been able to overcome his depression and lives a life of joy, meaning and purpose.

To me, Ray’s story illustrates the power of creativity to overcome emotional pain. Ray made a choice to create, rather than to stay stuck in his depression. Whether or not he becomes a famous singer, he is already successful. Likewise, in my work with clients, I want to know more not only about their symptoms, but also about their hobbies, their dreams and their creative interests. And for all the people who have told me they are “not creative,” I’ve yet to meet a human being who does not possess the ability to be creative in some way.

As therapists, we can be advocates for creativity, and pay attention to the ways in which our clients are already creative. We can hold the possibility of creativity as an asset that helps our clients thrive, instead of as a burden that they need to live with. Finally, we can see the therapeutic process itself as a creative practice, something which I’ll write further about in future posts!

Philip Kendall on Cognitive-Behavioral Therapy

Posted on August 9, 2012February 12, 2026 by rezendevknowfully.com

Working with the Masters

Deb Kory: Hi Philip. You’re a researcher, scholar, clinician, and a professor at Temple University. You’ve done a great deal of seminal work on treating anxiety disorders in children and adolescents, as well as cognitive behavioral theory, assessment and treatment. In doing research for this I opened up your CV and noticed that it was 127 pages long. You’ve been rather prolific over the course of your career and have worked with some of the great masters in the field of cognitive behavioral therapy. This month we’re releasing two DVDs that contain interviews with Albert Ellis and Aaron Beck. Can you tell us how these guys influenced you and what it was like working with them?

Philip Kendall: Tim [Aaron] Beck had an influence because my first job was at the University of Minnesota and I was hired to do research on children and adolescents in treatment and outcome. I worked with Steve Hollon there, whose office was adjacent to mine and he had just finished working with Beck on the first outcome study for cognitive therapy for adult depression. So I was influenced, in part, by Beck through that process.

Years later I now live about 10 or 15 houses from where Tim Beck lives here in suburban Philadelphia. He’s 91 now and moving into a townhouse in the city, but up until a few months ago we were neighbors and I’ve seen him at movies and restaurants and such. But the intellectual influence was the manualization—or manual-based approach—to treatment and its systematic, organized evaluation, which I was doing with kids and he was doing with adults.

DK: And how about Albert Ellis and Rational Emotive Behavior Therapy (REBT)?

PK: A number of years ago I did a paper with Albert Ellis that was intended to correct a slight trajectory difference. Tim Beck had succeeded nicely in pursuing the research side of cognitive therapy, whereas Al Ellis had succeeded beautifully in the practice side of rational emotive therapy, but not quite as much on the research.

So we collaborated on a paper that was intended to outline what was known and what were the next needed studies in REBT to try to correct its trajectory, which didn’t include as much research. I would say the focus is similar. Al Ellis focused more on neurotic styles and Tim Beck focused more on the diagnosis of depression. But, interpersonally Al Ellis was much more the New Yorker and in your face and Tim is not. And so, you have some therapist personality differences.

DK: What was it like working with Ellis?

PK: I guess I would say this: I found him to be very true to his view. His theory would say things, many of which are very insightful and smart, like, “you can’t be liked by everybody,” and “you can’t worry about what someone else is going to say if you say what you think is true.” And I found in my interactions with him around several things that he didn’t pull punches.

DK: He “called a spade a spade,” as he was fond of saying.

PK: Yeah, and I found it a likeable quality. And to be candid, in the paper that I ended up writing, it included some comments that were less than supportive, so we had a little back-and-forth and he accepted my criticisms.

I would say he was a little bit more inclined to want to look at the literature from a view that supported what he thought. I would say he [Ellis was a little bit more inclined to want to look at the literature from a view that supported what he thought.] And I would come from a perspective that says, “let’s look at the literature and think about what we know based on what we found.” That’s a slightly different read on how you process information.

DK: What other major intellectual influences would you cite?

PK: Don Meichenbaum was probably just a few years past his PhD at the University of Waterloo and he was working with kids. He had written some materials and they were literally printed on an old dot matrix printer and when he and I were communicating it was snail mail. So I would get these correspondences in the mail and I would send him our papers. I didn’t realize at the time that he was a leading thinker on this theme and that I was involved early in a major shift in our discipline. Mike Mahoney, Al Kazdin and Ed Craighead were colleagues at Penn State at the time and some of their work was also important and influential.

“These Kids Think“

DK: How did you come to psychology and to CBT in particular?

PK: I would say my initial training in psychology was with learning. First with animal learning, where you study the acquisition of behavior patterns in fish, mice, monkeys, white rats, that kind of thing. One of the features that we were studying was called “avoidance learning,” where animals learn to make responses that they think are helpful but, in fact, aren’t. And they just can’t unlearn those unhelpful avoidance responses, which is a very behavioral learning theory view of anxiety.

Then in graduate school, while doing a lot of behavioral work, the animals were no longer the animals. The animals were people. And it became apparent not just to me but to others that these kids think. And how they think alters their behavior. So we started talking about cognitive behavioral therapy as a way to take learning theory and still pay attention to the cognitive processing of the participants.

DK: Did you have any psychoanalytic training?

PK: I never had graduate level psychoanalytic training, but I did have several courses that were psychoanalytic and I remember reading a book that was about children and adolescents that was psychoanalytic, but it kept blaming the parents, and showed no reflection of normal development. It seemed like everything a normal kid would do or say was seen as a symptom, and that’s very disrespectful of the fact that normal development includes times of sadness, times of anxiety, times of conflict. Psychoanalysts didn’t seem to be informed by what we know about human development.

Psychoanalysts didn’t seem to be informed by what we know about human development. So I kind of rejected it, thinking it’s a rich theory and a couple of things seem right about it, but so much of it seems not based on what we already know.I hate to say it, but I think that was in 1974. Oh my goodness.

DK: That was the year I was born.

PK: And I was getting my PhD, oh my God.

DK: Well…and 450 publications later here you are.

PK: Yeah, it seems to have gone by quickly because time does pass quickly as you age.

DK: I’ve noticed that.

PK: But it also seems to have been relatively cumulative. What we know now is informed by studies that were done in the last two decades. And that’s a good feeling.

CBT Then and Now

DK: That leads to my next question. How have you seen cognitive therapy change over that time? Looking at Aaron Beck’s cognitive therapy and what you today call cognitive behavioral therapy, are there any majors differences?

PK: My hunch is it’s very, very similar. For example, in cognitive therapy for depression, even though the word “behavioral” isn’t in the title, it’s in the implementation of the therapy. There’s homework, there’s practice, there’s even scheduling and rewards. Those things are out of the behavioral tradition. In cognitive behavioral therapy there’s certainly practice and reward and homework, but there’s also the cognitive part. It’s just the title that was popular at the time.As far as what’s changed, there’s the good and the bad.

One of the dilemmas is that CBT has become more accepted and more popular—that’s a good thing—but in the popularization, more people seem to misunderstand it than understand it.

One of the dilemmas is that CBT has become more accepted and more popular—that’s a good thing—but in the popularization, more people seem to misunderstand it than understand it. I think our profession is well informed, but people outside the field have some long-standing misconceptions. “CBT—Isn’t that the power of positive thinking?” No, it’s not. “Oh, isn’t that where you tell yourself not to be depressed?” There are these simplistic, if not buzz-word answers that are just wrong and a misperception.

In addition, you have a sort of knee-jerk reaction among some—“Oh yeah, I read about that. I tried it. It doesn’t work.” But when you actually ask them, they didn’t really experience it or try it. Those things are unfortunate.

What’s changed for the better, I think, is the cumulative part. Psychology and clinical psychology is not a breakthrough science. It doesn’t change overnight based on one study. It’s a cumulative process that takes decades, not days, for things to go from point A to B to C to D. And when I see the American Psychiatric Association say they require clinically supported treatments such as CBT taught to their residents, and I see empirically supported treatments reviewed at a government level or by a state like California, and the programs that qualify as empirically supported are largely CBT, it’s showing the positive progress of cumulative knowledge.

DK: You’re being generous in stating that most therapists really know what CBT is. That’s not been my experience. We didn’t get a lot of CBT training in my graduate program. I’ve found in professional circles that CBT is often conveyed as kind of wooden, lacking in spontaneity, not focusing at all on the quality of the relationship, etc. Can you speak to that conception or misconception?

PK: Sure. And I’m kind of smiling. If we were on Skype you’d see a big grin because we just finished two large and, I think, important papers on the role of the relationship in CBT for anxiety in youth. The first is based on 488 kids treated at six different universities by close to 40 different therapists. The supervisors rated the therapists. The therapists had to send us tapes, which we watched and rated. The methodology of the study is really good.The bottom line is that therapists who are “teachy”—as in “Hi, Johnny, you’re anxious about this. Here’s what you should do”—don’t do as well as therapists who are more like coaches.

Therapists who are “teachy”—as in “Hi, Johnny, you’re anxious about this. Here’s what you should do”—don’t do as well as therapists who are more like coaches.

A coach would be more likely to say, “Johnny, you’re anxious about that. Hmm. What are some things we could try? What are some things that might have worked for other kids? Which one of those do you want to try?” And then try it out and say, “Hmm, that one seems to work okay for you. What do you think?” The coach style had better outcomes than the teachy style. Clearly that reflects different therapeutic relationships, different ways of interacting.

When you do an exposure task in treating anxiety, you take an anxious kid and you put them in a situation that makes them anxious. For years people thought, “Oh, that damages the relationship.” But the second study we did, also looking at the relationship, found that conducting exposure tasks does not rupture the therapeutic alliance. The challenges that are brought to a kid in CBT do not damage the relationship. It holds up pretty well. The relationship’s important. There’s variability in the way therapists do treatment. But relationship alone is not sufficient. It may be necessary, but not sufficient.

DK: There’s a lot of emphasis these days on more experiential, emotion-focused therapies that draw upon the adaptive potential of emotions and work to elicit deeply emotional responses within the framework of an empathic therapy relationship. CBT seems to focus primarily on cognitions and behaviors, but there is a fair amount of empirical support for the efficacy of emotion-focused therapies. How does CBT work with emotions?

PK: Again I have a little bit of grin on my face. Although the words are different—“expressed emotions” and “emotion focused” might not be the way we describe it—we’re doing much the same thing. For example, a child says, “I’m afraid to talk to people I don’t know.” So on Thursday at two o’clock, if she has an appointment, we set it up so that there are three other kids who are going to be there and this child is going to have an opportunity to meet one of them and have a conversation.And we say to this child who’s coming for the two o’clock appointment: “We have it set up that you’re going to meet someone else. What do you think is going to happen? How are you going to feel? What happens if you get all nervous? What happens if you feel your heart racing? What are you going to do if you get confusing thoughts? What are you going to do if you have to go to the bathroom? What are you going to do if you can’t think of what to say? What are you going to do if they ask you a question?”

Then we’ll go into the room. We’ll have the child being treated meet a new kid and every minute or two during that experience we’re going to say, “How are you feeling now? What’s your set rating? How anxious are you?” And then we’ll keep those ratings. Then when it’s over we’ll go back to the therapy room and say, “How’d it go? We can talk about it here. That was great! You said you were uncertain about what you were going to say, but you were able to come up with questions and he had the same interests you did in comic books.”

If you were to not call it CBT, you would see that anxiety, which is an emotion, was the primary focus. We were in the experience totally. We were getting their set ratings on a minute or two minute interval and we were very much focused on how he was reacting and feeling. It’s just somebody’s lack of understanding that contributes to the misperception of differences.

DK: So you’re saying there’s not a real split here between CBT and EFT?

PK: Right. There’s a common undertaking with the use of different descriptive language.

DK: Exposure therapy throws you right there into the midst of whatever really intense emotions you have.

PK: Exactly, but with proper preparation.

DK: But there certainly are some real differences in how emotions are conceptualized and responded to. In EFT or psychodynamic or existential therapies, the therapist often will dig into the emotions to better understand the meaning underneath the emotions. Isn’t there a real risk in trying to change the emotional response before it is fully understood?

PK: There are different opinions, with many folks saying that there is a degree of understanding within CBT, but in other schools of thought, the understanding alone is not enough. I would fall in this group.

DK: What about the unconscious? We certainly have plenty of empirical evidence that there is much outside of our conscious awareness, and as you know, in psychodynamic therapies excavating and bringing to light our unconscious beliefs, desires, drives, etc. is seen as an essential part of healing and becoming an integrated person. How does CBT conceptualize or make use of the unconscious—if at all?

PK: When asked if I believe in the unconscious, I answer “Not that I am aware of.” Kidding aside, the “underlying cognitive beliefs” are exposed as part of CBT. But, again, simply getting this to be more aware is not the end point, only a part of the goal.

CBT with Kids

DK: You’ve done a tremendous amount of research over the course of your career. In fact, you are one of the most frequently cited individuals in all of the social and medical sciences. I noticed that pretty much all of your research has been with children and adolescents. What’s the name of the clinic you founded and is that where the majority of your research is done?

PK: It’s called the “Child and Adolescent Anxiety Disorders Clinic” and I started it in 1985. Every child or adolescent who comes into the clinic pays a fee, but it’s a reduced fee. In exchange for the reduced fee, they agree to participate in research and complete all of the measures. So literally every child who comes through our clinic is a participant in research. And that allows for them to get carefully monitored services, including very detailed analysis of what’s going on and what happens in the end and pre- and post- and follow-up measurement and things like that. But it also allows us to have real clinical data with real patients. We have a small group of graduate students who are doing their master’s or their dissertation with funding we receive from NIMH, who are able to do a lot of pretty sophisticated work. So I think that helps the research productivity a great deal to have external funding, a real clinic, and bright, motivated staff and colleagues and graduate students.

DK: What was it about working with children that appealed to you?

PK: There’s a professional answer and then there’s kind of a silly one. The professional answer is that if you’re going to have an impact on how someone experiences life and thinks about the world, if you wait until they’re 20 or 30 or 40 years into it and have established biases and perceptions, your task is quite daunting and challenging.If you get to them early you can prepare them for these life experiences and catch—if not correct—some of the potential misperceptions when it’s developmentally appropriate. A first sleepover at age 12 is a meaningful social event; a first sleepover at age 30 is a different thing, you know.

DK: Indeed.

PK: The silly answer—and I have to be careful how I use the word patience here—is that I lose patience with adults. They can be rigid, misguided, less motivated and not quite as willing to try things. And I find with kids, they’re more willing to try things when they’ve got an adult who’s giving them some confidence to give it a try. And then it’s their own experiences that convince them to go forward. With adults there’s a lot of interference and baggage.

DK: I don’t automatically think of kids as having a lot of meta-consciousness around their thoughts and ideas. I think of therapy with children as being play therapy, where the therapist is making meaning of symbols and introducing ideas and concepts through a reparative relationship based in play. Do you still play with kids in CBT therapy? How do you incorporate concepts like homework and exposure into the play? Do they get homework?

PK: I’m going to do the homework part of the question first. We definitely have homework. Kids are accustomed to workbooks at school. They have math problems or other homework. So they also have homework in the “Coping Cat” workbook we developed, which they use as they go through their anxiety treatment.Rather than making treatment complicated and difficult, I try to make it acceptable to kids. So we’ll talk about a cafeteria of things like relaxation or talking back to your anxiety or trying things out to see how they work. You kind of walk through the treatment as a cafeteria, where you don’t have to eat everything that’s offered.

At first the homework is easy: remember your therapist’s name; write down a time that you had fun; write down a TV show that you’ve watched and enjoyed. You know, simple things.

But gradually that homework becomes the very challenge they need to do to overcome their anxiety. So homework later on in treatment, let’s say after 14 weeks, might be to enter a new group at school. Join the drama club, join the chess club, try out for a play, start a club with remote control cars. The aim is to do something that’s an initiation that might have been something they were so afraid of even thinking about months before.

So the homework becomes the practice of the skills that we teach them. It’s a very important part of CBT, because one hour a week sitting with us in a safe environment isn’t the real world.

So the homework becomes the practice of the skills that we teach them. It’s a very important part of CBT, because one hour a week sitting with us in a safe environment isn’t the real world. But if they’re out there doing what they’ve learned with us multiple times a week in the real world, that’s got some punch.

The other half of it you mentioned was play. And I have to be careful how I say this because I often put my foot in my mouth, meaning I misspeak. We do play with kids. But play is not the goal or the vehicle that’s crucial. Play is just part of what you do with kids to communicate with them. It’s more the context of building a relationship onto which you’re then going to add the challenges.

So as an example, if we’re talking about a misperception, a social misperception or a probabilistic misperception—and I wouldn’t use these words with kids—but the kid will think, “Oh, I can’t do that because lightning will strike me.” We might say, “Oh, yeah, lightning. What would happen if you got struck by lightning? Let’s look it up on Google or let’s do some homework. What are some things that increase the chances? What are the things that decrease the chances? Holding a metal rod increases the chance. Golfers hold golf clubs. Let’s see how many people play golf, how often, that have how many clubs,” and then you’re playing. But in the game you come up with the conclusion that it’s one in 64 million people who might get a bolt of lightning on a golf course with a golf club. The probability isn’t that high.

DK: So you’re disconfirming the fear.

PK: Right. And again it goes by that coach notion. When a kid comes in and says, “I can’t call a friend on the phone. I don’t interact with peers at school. I don’t raise my hand. I’m scared of what’ll happen,” we think of it as, okay, in 16 weeks we want the kid raising his hand, calling a friend to ask about homework and having a sleepover.In other words, the things that are difficult are the things we’re going to do. And how would a coach get there? A coach wouldn’t say, “You have to do it today,” because you haven’t taught them how. Just like a piano teacher wouldn’t say, “Perform your recital” the first day of your lessons. You have lessons, you practice and then you have the recital at the end.

So in our 16 weeks we’ll have lots of practice at pretend-calling people, at pretend-raising your hand, actually raising your hand in front of a staged audience, having catastrophes happen and helping you deal with them. So that when the kid goes to school and part of their homework is to raise their hand and ask a question, they’re kind of into it and practiced and know what to do. And that’s part of that coach notion that we allow them to have practiced at the things that may or may not happen so that they know how to deal with them if and when they do happen and it’s no longer so frightening or new or novel, it’s, “I’ve done that before.”

DK: Well that sounds different from one of the conceptions or misconceptions that people have about CBT, which is that the therapist is the “expert”–as opposed to, say, a more non-directive Rogerian approach or even the semi-directive approach of motivational interviewing, which guides clients with open-ended questions and seeks to “meet clients where they are.”

PK: In our approach we look at it a little differently. We say, “You’re the expert on you, Johnny. I’m sort of the expert on what other kids have tried and learned from. But I can’t do it without you and maybe you can’t do it without me. So we have to really collaborate on this. And I can give you some ideas for you to try out, but you have to tell me what works and what doesn’t work.”

DK: These approaches certainly make a lot of intuitive sense, especially when there is some clear behavioral change that is desired. But how does CBT think about situations where the emotional response of the clients seems appropriate—e.g. a girl is understandably distressed about her parents’ divorce, and she really just needs someone to talk to and work through her own feelings. Does CBT have anything specific to say about a situation like this?

PK: In general, the goal of “treatment” is to remediate an identified problem. For emotional disorders, for example, there may be irrational thinking or illogical processing that is interfering and maladaptive. These problems need to be treated.In cases where someone has a “genuine and real” reaction to a real situation that is not excessive (though reasonably distressing), the rationality isn’t faulty nor is the thinking illogical. Rather, these are relatively normal processes that don’t meet criteria for disorder and don’t necessitate treatment.

If someone wants to have “personal growth” and learn about their thoughts, feelings, and behavior, that’s fine, but it’s not the same as effective treatment for an identifiable problem.

“I Must Be Doing Something Right”

DK: Of your many roles—teacher, researcher, writer, clinician—what’s your favorite?

PK: How do you pick a favorite child?

DK: Well, parents usually secretly have one….

PK: I don’t think I can pick a favorite. I can maybe rank them on different dimensions. I get a great deal of satisfaction from mentoring and seeing people go on and have their own careers flourish. I get a great deal of pleasure out of kids who were scared shitless (pardon my language) when they came in, going on to do things and 16 years later we’re in touch with them and they’re doing well. I like that stuff. That’s very satisfying. And then professionally I like doing good research and publishing it in good journals because I feel like that communicates to my colleagues, even though I recognize that the impact takes a long time.

DK: Okay, final question. I’m just starting out. I’m about to get licensed and I’m just wondering what advice you have for new therapists in the field.

PK: Every happily married person had been turned down prior when asking for a date. Every successful book author has had a proposal not go perfectly well. Every successful scientist has had a paper not accepted on first submission. And the best basketball player on the planet, Michael Jordon, shot 49.9 percent for his career. So having things not go well should be expected. And doing the best treatment you can might mean four or five out of ten get better. And if you do that, you’re doing better than most. Our profession is such that we remember the ones that don’t work and we blame the treatment we’re doing for its failures, rather than an objective view which states that this treatment response rate of 60 percent is 20 percent better than anything else, so I must be doing something right.

DK: That’s lovely. Thank you.

Grief and Gratitude: Working with Stroke Survivors

Posted on July 9, 2012February 11, 2026 by rezendevknowfully.com

Together

May we sit with wisdom and compassion

at the ancient fires

of dashed hopes

and lost dreams.

May the pain which brings us together

become the cave we enter

in reverent descent

and surrender

to what

IS.

May we have the courage

to bear this rebirth

together.

—Carol Howard Wooton

An Interruption

In 2005, our circle of six met in a poorly lit room of a community hospital. This afternoon, Tom had the floor. A former surgeon, he had been looking forward to cutting back his practice to spend time with his grandkids.

Tom had lived his life in constant motion. He had been a football star in high school and college before going to medical school. Now, at 67, he was paralyzed on his left side: his left forearm contracted in spasm, his once-dominant left hand clenched into a permanent fist in front of his belly, his left leg rigid below his knee. His chiseled face still handsome, he sat straight in his wheelchair, strong muscles supporting his torso—a powerful presence. But his eyes always gazed down; he barely looked at anyone.

“I used to be able to ski, drive, do everything around the house,” he said. “I loved my work. This summer, I planned to take the grandkids to the ocean, show them how to dive into the surf. What can I show them now? Nothing.” The other group members listened quietly to his grim litany; all of us recognized his truth.

One day in 2004, Tom had come home from work and eaten dinner as usual. His wife was in the next room when he felt himself lose balance and topple over. He called out to her.

“I’ve had a stroke. Call 911,” he told her from the living room floor. She made the call, then came back into the living room and sat her petite frame on Tom’s head until the paramedics came, knowing he would try to get up.

“I had it all planned out,” Tom said to us. “And now I can’t do any of the things that I want to do. All that time I spent in medical school and working hard while my wife raised the kids—this was supposed to be my time with my grandchildren.” Each week he repeated these thoughts while gazing at the fingers of his left hand, pulling each one out as straight as possible, then resting it on the arm of his wheelchair or in his lap. On this day, the door banged open, interrupting him.

In barged a large woman in a motorized wheelchair, which she drove fast and well. Her left leg was swollen huge, the bare right foot discolored, her skirt hem hardly covering the Foley catheter bag strapped around her calf. In a croaking voice, she declared, “There’s only two kinds of people in the world: keepers and assholes. And you’re all keepers!”

Everybody, including Tom, guffawed. Amidst the belly laughter, she zoomed over to our small circle, which had opened to give her room. She told us she had been sitting outside in the warm air for 45 minutes, thinking she was early. When no one else arrived, she’d opened every unlocked office door until she found us, arriving with only 30 minutes left in the session.

“Hi there,” she said with a wide grin. “I’m Alexandra.”

None of us could have guessed that day how much Tom and Alexandra would change each other’s lives.

The Group

When I’d spoken to Alex on the phone for the group screening, I hadn’t been sure whether I should allow her in at all. I could tell immediately that she would be a handful. She spoke nonstop. Her history included two violent deaths in her family and probable childhood verbal and physical abuse. There was no way to determine what aspects of her personality resulted from the innumerable medications she was taking, and what was caused by her stroke and or by PTSD. The nurse case manager referred her to me because of her complex medical conditions and because the psychosocial situation at home was especially difficult. Along with the stroke, which had left her completely paralyzed on her left side, she suffered from diabetes and lymphedema. Her husband was away at work or commuting during their waking hours, leaving Alexandra isolated at home with only the companionship of a part-time caregiver.

Any group therapist would have been concerned about the severity of her situation, her apparent need for attention, the feasibility of containing her, and the unpredictable impact she could have on others. However I also realized that she needed the group and had many stories that needed witnessing, as well as much wit and spice to offer her groupmates. And this was my mission: to create a community of belonging for stroke survivors to grieve, heal, grow, and keep hope alive—the space I wished I’d been able to find in the first years of my own “recovery.”

The Beginning

“I had a stroke in 1985. I was 38, with no high-risk factors.” Having just been minted as a licensed MFT, I was living a typically stressful existence building a practice and taking whatever jobs I was offered. It happened at a work-related event, a friendly barbecue for a support group of women Vietnam veterans which I co-facilitated. All of a sudden, I grew dizzy and wasn't sure if I was sitting up straight; the world receded to a distant buzz. I slept on the hostess’s couch that night, unable to drive home. When I woke to find I couldn’t stand, or even crawl, she brought me to the ER, where my husband met me.

The neurologist diagnosed me with a cerebellar stroke or CVA, etiology unknown, and gave an excellent prognosis: I would be fine, and it would take a while to learn to move again, to walk, to have a brain that worked at “normal speed.” When I asked what “a while” was, he hedged. “Six months from now, you and your husband will know,” he said finally, “but other people probably won’t be able to tell.”

Six months later, that was not true. Two colleagues who had suffered a stroke and a traumatic brain injury, respectively, told me, “Don’t worry about your progress for at least a year or even two. Just keep at it, no matter what.”

“You Don't Get It”

Before my stroke, I’d consulted with a therapist named Helen on my own cases. She was a smart, warm, empathic woman several years older than me with a well-established practice. Within 24 hours of my hospital admission, I asked my husband to call her: I needed her help in formulating a plan for handling my caseload. After we made arrangements, she continued to call me during my rehabilitation. Our regular contact reminded me of my professional-self while being a patient.

Returning home a month later brought me face to face with my new limitations outside the safe hospital environment. I was frequently overcome by waves of strong emotion, mostly frustration and sorrow. I determined that weekly psychotherapy would assist my physical recovery. My therapy with Helen began on the phone; when I was able to leave the house, my husband or a friend would drive me.

My neurologist had advised to me to wait six months before driving. After about nine months and many practice drives with my husband, I drove myself for the first time to Helen’s office. “During the entire drive from San Francisco to the East Bay, I held onto the steering wheel so tightly that my knuckles turned white”—not out of fear, but because I wanted the pressure of my hands against the steering wheel to anchor my attention. Without that strong sensation reminding me to keep my eyes on the road, I might have become so riveted by anything moving alongside me—the beauty of leaves dancing in the wind or the blue BMW passing me—that I might forget about looking straight ahead.

I was drained by the time I reached Helen’s office. “You made it! How was it?” she asked.

When I mentioned that it was hard for me to concentrate, she replied, “Oh, that sometimes happens to me, too. I’m driving and thinking about what I’ll buy at the grocery store or the calls I need to make.”

With a pit in my stomach, I realized, “She doesn’t get it. It’s not like that now.” I didn’t have words yet to tell her how it was for me, or to explain to her what she was missing. So I said nothing.

It happened that I also knew a therapist who had suffered a traumatic brain injury in a car accident. I knew he would understand, so I began to meet with him. Together we explored and named the difficult parts of our experience: slow thinking, unreliable memory, trouble concentrating, having to relearn everything, wanting to be “normal” while also being impaired. He supported me with anecdotes from his own experience and comments indicating that he understood. This was enough to allow me to go back to Helen and have the words to talk with her about our rupture.

“No, no, no, you didn’t understand,” I told her when I returned. “Part of me wanted to pass as normal, as someone who’s simply distracted by making a mental shopping list. Not being able to rely on my capacity to direct my attention was frightening.” As we talked, I came to understand that her well-intended response grew from her wish to join with me to help me feel understood and less flawed. Later, we also spoke of her fear and grief in the face of all my sudden losses.

Be Curious

As I learned with Helen and would keep learning in my group work, it’s essential for a therapist to acknowledge discomfort in the face of the sudden profound loss of physical, communicative, and cognitive capacities, all highly valued abilities that may lead to loss of social, family and vocational roles—loss of identity. Making assumptions that he or she understands is a great defense against that discomfort, but it doesn’t help the client.

Therefore, it is especially important to practice curiosity. When clients say something’s hard for them, ask, “How,” or, “What’s that like?” or “What’s that mean to you? Exactly what part of it is hard?” “Asking questions like these gives the survivor an opportunity to attend to inner experience and attempt to articulate it.” Stroke survivors’ process of authoring their own new stories enlarges rather than diminishes their sense of self.

The process of articulating a narrative doesn’t happen during rehabilitation, which currently averages 16 days in the U.S. There, the focus must be on the rapid regaining of lost function so the discharged patient can perform as many ADLs (activities of daily living) as possible: the basics like sitting up, transferring from bed to wheelchair, standing up, walking, toileting, climbing up and down stairs, swallowing, feeding yourself, putting your pants or bra on.

Since there is little time and training for rehabilitation staff to focus on enhancing the patient’s new identity, we therapists have a big job. It is all too is common for patients to feel diminished and “less than” in medical settings: imagine having to focus most of your attention on exactly what you can’t yet do. How we respond as therapists, friends, and family makes a big difference in the healing process.

Sometimes it can be hard for a therapist to remain curious when a client seems to simply repeat the same story over and over, as Tom did. But consider this: it’s exhaustingly hard work for an already injured brain to develop new neural pathways. This spurt of neuroplasticity is nonetheless necessary for both physical and emotional recovery. No wonder survivors often repeat the same stories; pure neurological exhaustion can lead anyone to opt for the better-established neural route. If you keep hearing the same story, you might want to say, “I hear you. You are working so hard just to stand up again.” Follow-up questions will prompt clients to experiment with new thoughts and stories.

Finding a Community

Even though I had loving friends and a devoted husband and family, I felt isolated when I returned home. After the crisis, my life consisted of weekly physical therapy—learning to walk again, regaining strength—and resuming tasks like buying groceries, balancing my checkbook, making dinner. Meanwhile, my friends and family went back to their busy lives. I was left moving through my day incredibly slowly, and mostly alone.

“I began to wonder: “Where do I fit now?” What were my chances for a career, or any role in society?” Would I be able to resume a full professional life like my colleague who had a traumatic brain injury?

Three months later, with the help of my therapist Helen’s consultation, I resumed seeing one client a day in my home office. Despite lingering but outwardly subtle attentional difficulties, I discovered that I could still listen deeply and skillfully to one person at a time. After walking my client to the top of my long stairwell, I had to rest for several hours before a simple dinner with my husband and bed. Still, this was a personal triumph, and the beginning of reclaiming my professional confidence.

I also began to search for a community group where I might find guidance and a place I could belong. City College of San Francisco had a program for Acquired Brain Injury survivors, but the organizer told me I was too high-functioning. Yet I was not high-functioning enough to occupy my own life in the way that I had before.

Through friends, I found my way to the Stroke Club, which met monthly at a local YMCA. First I was a guest speaker, then I became the volunteer co-leader. The group provided the opportunity to test my ability to perform professional functions I had used before my stroke. I was pleased to find that my attentional difficulties didn’t interfere with my ability to lead the group. In fact, I proved to myself and to others that I could still conduct a group class for a few dozen adults, using my skills as a counselor and educator as well as my personal experience to serve others as we learned to cope with life after stroke.

The Stroke Club provided social connection, education and some support. It was perfect for some, but it didn’t satisfy the therapist in me. My professional experience as a therapist working in a psychiatric halfway house and with Vietnam vets had taught me how potent small group intervention is for marginalized and stigmatized populations. I wanted to start a small group for stroke survivors. But how?

After hearing a local neuropsychologist give a talk to mental health professionals about his group work with brain-injured adults, I called him and told him my idea to organize a group for folks who’d had strokes. He suggested we talk more over lunch. He was very encouraging. After we discussed logistics and recruitment, he asked me, “Are you going to volunteer to do this?”

“Well, I’ve been volunteering for the last two years and seeing clients in my private practice,” I responded. “I’d like to ask people to pay me. I am a therapist, after all.” In response, he expounded on the rewards of volunteering. It was as though he was saying, “Oh, you’ve had a stroke? I’ll let you volunteer. Oh, yes, I think you’re competent, but you want to charge money?” I held my ground, and was proud of myself for doing so, despite my own still-shaky sense of self-efficacy.

To his credit, he listened, thought about it, and said he would try to work out payment. A few weeks later, there was an envelope waiting for me in the staff mailroom of his hospital, St. Mary’s, where my group had begun. He had written me a personal check.

When I asked him about it, he told me, “We can’t get the money from St. Mary’s yet and I often make donations. I know you and think this is a good idea, why not help you launch this? Seems more important than giving to United Way.”

This was a pivotal moment. Not only was it a kind and generous gesture, but even more than that, it was a sign of the neuropsychologist’s professional dedication and esteem. Neither of us knew for sure where I belonged in the medical model—star patient or competent professional. The donation moved us both across an invisible threshold.

A Different Kind of Challenge

The loss of competence and control over his daily life was understandably trying for Tom, the former surgeon. During his first years with the group, he said no to every suggestion that his loving family offered, most especially his wife. He refused physical therapy. He refused occupational therapy, though his wife had already arranged his eligibility and prescription. “No, no, no, no.” The only suggestion he took was coming to this group, which his wife had also recommended, worrying about how little he left the house. She had to learn to tolerate Tom’s “no.”

It was easier for me, as the therapist, than for Tom’s family to see that “saying no was the only control Tom could exert in his life.” Still, I advised them that if they could just let it be and stop pushing, maybe he would say yes, but on his own schedule.

Of course, I did break my own rule occasionally. Countless times over the course of the group, I had given Tom the name of an extremely talented and competent physical therapist who specialized in neuro-rehabilitaton. Each week, I would ask him, “Did you call her?” And, like a high school student, he always had an excuse. “I spilled coffee on it.” Or, “I’m going to call. I just haven’t gotten to it.”

Finally, I called the physical therapist and asked her if she would come to the group in order to provide a short lecture and demo to all the members. She knew that I had referred her to Tom. When she came, she made a special pitch to him. We watched her use all her strength and skill to pull his contracted left arm as straight as she possibly could against the resistance of all its spasticity. His look of surprise grew into a smile as she uncurled his fingers one by one and placed them on his lap. It helped, of course, that she was confident and attractive. Finally, he asked her in front of the group, “When can you come over?”

Over the next several months, Tom progressed from being wheeled into the room in his wheelchair, to walking while holding onto the chair with his caregiver nearby, to using a four-pronged cane while his caregiver wheeled the chair in behind him.

The group witnessed and applauded his progress week after week. Nevertheless, Tom’s grief trumped all: “Yeah, but the wheelchair’s still here.” “Yeah, but this isn’t really walking. Walking would mean that I would be out there on my own again.”

Tom’s despair did lead him to make a suicidal gesture. I classify it as a gesture, not an attempt, because he did it at home, with his wife in the other room and the physical therapist scheduled to come.

After this incident, Tom didn’t return to the group for a while. When he did, it was clear something had shifted. Before his stroke, he had always been healthy and well adjusted. He had lots of great coping skills that had enabled him to focus on achieving external goals; he hadn’t had a reason to reflect on his interior life. Now, even though it was physically and emotionally painful, Tom was learning how to face and cope with his own despair. He began to see a cognitive-behavioral therapist who helped him utilize his intellect to gain insight into his own thoughts and feelings. In this way, he learned about depression.

When Tom came back, he was initially subdued, and at the same time, sardonic—a new sign of energy appeared in his eyes and voice. His mantra became, “Well, I guess I’m not going to be taking the grandkids to the ski slopes,” as opposed to wishing he could. He hadn’t yet fully accepted his new life, but he was getting there.

The arrival of a new group member soon afterward gave Tom the push he needed. George was also in his late sixties, a medical professional, and paralyzed on his left side. Only several months post stroke, he was still wheelchair-bound. But George had explored his dark side prior to his stroke: he’d been in a 12-step program for years.

One day in group, George addressed Tom point-blank. “You were a surgeon,” he said. “You knew what to do if you wanted out.”

Tom had met his match. No more BS. George called him on his actions, and set him some new expectations. He wanted Tom to be a role model. “How long did it take you to stand up on your own?” George would ask him. “What do you think about stem cell transplants? Neuroplasticity?”

They met man to man, and began swapping golf and football stories and off-color jokes. With George’s support, Tom not only became the group’s in-house physician and renewed his medical license: he had found a new role for himself.

Look for Wholeness

Tom’s struggles exemplify the profound grief and loss that can engulf a stroke survivor’s perspective. As the facilitator and a fellow survivor, it was hard for me to hear Tom’s despairing litany week after week. While the group had made space for Tom to speak his dark truth, I also knew from personal and professional experience that it was possible to move beyond the focus on what had been lost.

It is crucial for survivors and their therapists to know that recovery doesn’t stop at six months or a year, or even at two years. Now, with new research into neuroplasticity, we know that people can continue to progress 10, 15, even 20 years after a stroke. Although, there is no way to know how much healing is possible for an individual survivor.

Oftentimes, people become focused on regaining their capacity to ski, like Tom, or to go back to work. But if the goal is too concrete and narrow, they might be severely disappointed. It took a couple of years to go from mastering the stairs to my apartment to being able to walk six miles; in order to appreciate my successes, I had to stop comparing myself to who I had been.

Grieving is necessary, along with the acceptance that there’s a new normal. That’s why I hate the word “recovery”: it implies a return to a prior state. But moving forward from a stroke is not as simple as trying to get your life back to the way it was before, because it will never be the same.

So instead of aiming for the impossible goal of returning to a previous state, clients must re-imagine themselves and their lives. The term I have chosen, for lack of a better one, is “revisioning.” And neither feeling—the sense of loss nor the sense of possibility—ever goes away completely for a stroke survivor. “I think that the best outcome for folks with strokes is that grief and gratitude live side by side.”

A Good Boy and a Bad Girl

As the group progressed, Tom and Alexandra formed an unexpected bond. They seemed like polar opposites: he was the quintessential altar boy, the high school football star, the successful surgeon. He did the best he could at whatever was in front of him. On the other hand, Alex was a troublemaker who questioned authority, and who gave everybody a hard time probably from her first words. Tom and Alex had actually gone to the same religious school, but Alex had been suspended for asking questions about birth control.

When, week after week, Tom was stuck in his “yeah, buts”—“I walked a little further with my physical therapist this week, but it’s still not throwing a football” —Alex would finally be the one to say, “I’ve had enough of that. You’re just feeling sorry for yourself. Come on, I’m happy for you! You’re out there walking. If I could walk, I would be really happy.”

Tom would break his self-absorbed downward gaze at his spastic left hand and look at Alex, in her motorized wheelchair, who hadn’t stood on her own two feet in who knows how long and wasn’t going to be walking two inches. That stopped him dead in his tracks.

Alexandra’s directness and her outrageous sense of humor unfailingly got her the attention of the group, along with her stream of hilarious stories about her past traumas and clever triumphs during her checkered career. Her level of her socioeconomic dislocation and physical disability was also the most profound in the group. Her husband ended up losing his job, so they lived on food stamps and MediCal.

When Tom had been absent from the group following his suicidal gesture, I used the opportunity of that emotional upheaval to ask, had they ever felt suicidal? We all talked about our own moments of despair and discouragement. Alex’s half-joking response was, “Suicidal? Heck no. I might have felt homicidal.” And the truth was, that’s how she dealt with things. Because of the extent of her disability, she was constantly undergoing humiliating and painful medical treatments. Instead of becoming passive and defeated, she chose to be a “difficult patient.”

Alex had a suprapubic catheter, which went through a hole in her abdomen directly into her bladder and had to be changed weekly. Sometimes, predictably, this routine procedure was very painful. Once, Alex related a story about a nurse who replaced the catheter especially roughly, jamming his elbow in her face in the process. She begged him, “It hurts! Stop! Please stop.” When he ignored her, she bit his elbow hard enough to draw blood. She laughed raucously as she told us this story. And while we appreciated the comic relief, we were horrified at what she had been put through, and awed by her behavior.

Though I had initially worried about Alex dominating or disrupting the group, I learned to let her have her way and to let her speak. She also learned to restrain herself when I glanced her way. The group’s attention began to transform her. Alex was always self-aware enough to know that she played the role of the bad girl, and that she used her own humor as a defense. Over time, she began to able to talk about what was really difficult for her, without the defenses.

For instance, in order for Alex to get out of bed and be put in her wheelchair, because she was large and because she was completely paralyzed on one side, a machine called a Hoyer lift had to be used to move her around. After several years, Alex began to talk more about her own sense of humiliation and discomfort around this device. She once told us that, moving her from her chair to her bed, her husband had dropped her by mistake. She told this story without her normal humor and outrage. She let her sense of vulnerability be seen and felt. The empathy and resonance in the other group members as she shared was palpable.

She also began to name some of the things that were especially difficult for everybody to talk about: What it’s like to be incontinent. What it’s like to wake up in a bed filled with your body fluids, and have to wait for somebody to come change you. Her bringing up these difficult moments in turn freed up some of the more reticent men to comment on the reality of those experiences for them.

So, as it happened, Tom, the good boy in the group, was learning from the “bad girl” about how to resist passivity and defeat in the face of his condition. And at the same time, the bad girl had gained the attention, respect, and admiration of the surgeon, the archetypal good father. Thanks to these relationships and the support of the group, Alexandra gradually moved from being the negative leader who challenged authority—mine and everybody else’s—to becoming a positive leader and thinking about herself in a constructive way. I believe that the group’s curiosity and openness to her perspective of the world allowed Alex to fully own not only her story but her personality, her own way of being.

Warrior Heart

The extent of Alexandra's transformation became clear to me when she organized an award ceremony for the group. She came up with the idea of awarding a former group member with the Warrior’s Heart Award. The award had been inspired by a group conversation I initiated about what it means to have a strong heart and be courageous. In that discussion, most of the members, including Alexandra and Tom, had agreed on John.

John was in his early forties, with red hair and an elfin smile. He used to be a chef, and still loved food. He was partly paralyzed and had expressive aphasia, which means he understood almost everything, but his verbal capacity was limited. He spoke primarily with gestures and facial expressions: his hand on his heart, wide smiles, quizzical looks. He had joint custody of his eight-year-old son, for whom he prepared meals with his one functional hand. And even though he was partly physically disabled and his speech was limited, he was always out in the community, swimming, grocery shopping, helping with events at a local community center. When people saw him around, he was always happy.

When Alex brought up the idea of the ceremony, I agreed it would be wonderful. I decided to wait and see if she was serious about putting effort into helping to make this happen. Several months later, Alexandra approached me about it in the group. “What about the celebration, Carol? Are we going to do this? I really want to.”

And so, with the group’s help and Alexandra’s leadership, we put on the First Annual Keeping Hope Alive Warrior Spirit Award Ceremony. It was moving to see her in her new role: as a leader, an organizer, an eloquent writer. For the award ceremony, she composed a poem that captured for all of us the strides we continue to make together as a group:

“John, you stand tall
your head above others, your back straight.
You are universally liked, your friends, legion. You inspire
us with your dogged
persistence in the face of challenges that defeat others.
Your warrior spirit proves to the rest of us, you are our representative
as we stand upright against the vagaries
of our conditions, and proof we will recover,
and contribute to each other’s success.
Thank you for being who you are:
Our warrior spirit.”

[This article was written with the consent of the group members portrayed therein.]

Paul Wachtel on Therapeutic Communication

Posted on July 6, 2012March 13, 2026 by rezendevknowfully.com

The Third Wave in Psychotherapy

Ruth Wetherford: Along with being the distinguished Professor of Clinical Psychology at the Graduate Center at the City University of New York, you’ve won many honors and awards throughout your career, including, in 2010, the Hans Strupp Award for psychoanalytic writing, teaching, and research. You’ve also been called one of the leading voices for integrative thinking in the mental health sciences. What does that mean?

Paul Wachtel: I think what that refers to is that for many, many years now, it has felt to me that psychotherapists operate like battling ethnic groups. They stereotype each other. They’re overly attached to their own language and make fun of the language of the other. They gather in their tribe-like congregations and miss a lot of value in the other orientations. So my interest has been not only looking at what has been called the common factors–the processes of change that are common to many orientations–but looking also at the differences, and how we can put together what’s similar and what’s different and create a more comprehensive approach to theory and to therapy.

RW: What are some components of what you want to be your message, your legacy?

PW: What’s important is getting ourselves out of the ethnic battles and thinking instead about what’s really of value to people. I was originally trained psychoanalytically, and then became interested in behavior therapy and then cognitive-behavior therapy, and then also family systems and emotion-focused approaches. One of the things I learned from the behavioral and cognitive-behavioral end that has profoundly influenced every moment that I think I’m working psychoanalytically is the absolute importance and compatibility of the exposure paradigm. Much of what promotes change is the experience of repeatedly confronting and being exposed in a full, emotional way to the aspects of our lives that we have turned away from in fear or guilt or shame. Sometimes those can be external stimuli like a phobic object, but very often, they’re our own thoughts and feelings and experience of self. What I’ve learned from cognitive-behavior therapists, and I never forget it for a minute in my sessions, is that

it’s not enough just to name it, interpret it, label it. You have to experience it. And that’s a place where the cognitive-behavioral and the psychodynamic can converge in powerfully important ways.

RW: This reflects, I think, what Dan Wile works toward in his collaborative couple therapy when he says that it’s important for the therapist to continually monitor internal thoughts, feelings, and impulses toward clients or patients we find in some way offensive–to continually look toward why that’s offending us and to look for what may be legitimate or reasonable. How can we understand it from that person’s point of view? It seems like it’s inherently about the therapist’s capacity to see things from another person’s point of view.

PW: I think job number one for a psychotherapist is to be able to understand how the world feels and looks to the people we work with. That’s another interesting point of convergence, by the way, in the larger realm of psychotherapy, that the ethnic waters are making less apparent than they should. In cognitive therapy, in particular, practitioners actually fall prey to the very errors that psychoanalysts fell prey to, which was thinking that if you just say the right words and label things and get people to think right, you’ll do the job. They will often treat the client’s thoughts as irrational and erroneous, and that’s very much the opposite of what you were just talking about.But there has been a trend in CBT in recent years that’s often been described as a third wave, that includes dialectical behavior therapy (DBT)–Marsha Linehan and her colleagues–and acceptance and commitment therapy (ACT)–Steven Hayes and his colleagues. Central to both of those are two things that create potential convergence with psychodynamic and experiential therapies: an emphasis on acceptance of the person’s experience, and a respect for emotion that was largely excluded from CBT for a 20- or 25-year period.

When I first got interested in behavior therapy, I was interested in it not because it was behavioristic, but almost for the opposite reason—that it was actually very deeply experiential. Instead of just talking about what you were afraid of, you actually put yourself there. I listened to what clients were saying and what they were feeling as they were confronting it. That experiential element was very important. I learned a tremendous amount from the early behavior therapists, so I was stunned to see tapes of the very people I had learned so much from, when they started to fall under the sway of this rationalistic approach to cognitive therapy. Suddenly they were trying to talk people out of their feelings, trying to tell them, “If you think right, you don’t have to be sad. If you think right, you don’t have to be angry.”

What DBT and ACT do, instead of trying to talk people out of the feelings, is they go into the feelings. They validate them. They accept them. They bring them forth much the way a good experiential or psychoanalytic therapy does. And that’s combined with an interest in eventually promoting change. There’s a seeming paradox there, but I think Marsha Linehan’s term “dialectical” captures it well. It’s a term, by the way, that’s also used by Irwin Hoffman, a relational psychoanalyst. It is that tension between acceptance and change, between following the protocol and varying from the protocol. Hoffman calls it going according to the book and throwing away the book. That’s how we work most effectively.

“What Should I Say?”

RW: One of your most important messages from your earliest works through the new edition of Therapeutic Communication : Knowing What to Say When is about our faulty assumption that if we truly understand the person, we will automatically say what we intend to say that will be effective in this dialectic between acceptance and change. Say more about how you want therapists to acknowledge this assumption, and what to do about it.

PW: The importance of that was something I learned almost incidentally, though powerfully, taught unwittingly by my supervisors on the one hand and my students on the other.My supervisors taught it to me by its absence. In other words, I became aware that asking questions like, “What should I say?” opened me up to charges of being superficial and literal. The message I often got was exactly what you’re saying: “If you understand it, you’ll know what to say.” So for a while, I was just feeling, “Well, maybe I’m stupid. But I think I understand the dynamics pretty well, and I seem to be understanding them much the way my supervisor agrees they are.” Yet sometimes I wasn’t sure what to say.

As I began to think about that more and talk about it more in my teaching, my students made me aware that they were getting something from me that they weren’t getting from any of their other teachers. They would say, “When we talk to you, you actually talk about what we should say. We’re not hearing that anywhere else.” That’s what first got me interested in writing about those details.

Then that got me really thinking, as I’ve continued to do over many years, about the ways we talk to people, and all the ways it can be problematic, the ways it can be helpful, and how it both shapes and is shaped by the ways we think about people.

RW: One of the ways you have demonstrated your gift for feeling is in your discussion of the implied message of different word choices. In other words, you talk about the focal message and the meta-message. You’re so attuned to the connotations of words and how they carry the meaning of respect or acceptance, versus accusatory, pejorative meanings. And this is the thing that so many therapists you’re trying to address seem tone-deaf to. They can hear a recording of an interaction they’re having. Others can see that it’s coming across critically or accusingly, and they can’t hear it. How do you address that?

PW:

Hearing and understanding the tone of what we’re saying is one of the hardest things for people to do. It’s one of the most important,

Hearing and understanding the tone of what we’re saying is one of the hardest things for people to do. It’s one of the most important, and I think people with good interpersonal skills do it naturally. I think it can be trained. But I do think it is hard.

One of the examples that I’m always struck by is if you’ve ever been in an unpleasant interaction with a sales clerk at an airport or something like that, often if you say something about what’s going on, they will say, “Why are you getting so upset? I haven’t said anything wrong.” And if you look at the manifest content of what they’ve said, that’s true. But if you listen to the tone of voice or you hear the way the sentence is constructed, you know you’re meeting with a hostile response. But the person who is being hostile or dismissive toward you often doesn’t understand that. That’s one of our real challenges.

On Modeling

RW: I read recently in a neuropsychology article that so much of our brains, particularly the right hemisphere, are designed to assess how we’re doing with another person, constantly monitoring, second by second, where we stand vis-a-vis that person. Tone of voice is one of the primary ways of doing it, along with facial expression, eye contact, body language, and that sort of thing.But we have a culture that is so dismissive, many people don’t know that tone is important, even though they’re constantly reacting to it more or less unconsciously. I like to use the phrase TODD: Tone of Disapproval and Disdain. I’ll point out to people when TODD has entered the conversation. And when people go from thinking tone is not important to realizing it is, that’s a huge opening. Bringing that message to people seems so elementary, doesn’t it? How do you cope with that?

PW: I think one of the things that we do, whether as teachers or as therapists–and here, I depart from the traditional psychoanalytic view’s emphasis on autonomy–

RW: Oh, no. You’d better not do that.

PW: I’m going to do it. Brace yourself.

RW: Radical!

PW: The idea of modeling is a very, very important one. We offer ourselves as models. Not that we’re model human beings, not that we’re any better as people or any more effective as people. But when we’re attending to the tone, to the effect, to the relationship, and when we do it well, our patients pick that up from us.I’ve had patients say to me without our ever to having talked about it explicitly before, “You know, you always manage to say what I’ve just said in a way that feels like you hear it, you care about what I’m saying. It sounds better in your words than it sounded in my mind. But I’ve begun to learn to say that to myself now.” And it’s not that I’ve asked them to. That would be an authoritarian, mechanical way. But the modeling or identification that goes on is selective. The patient will take what works for him or her.

And it occurs mostly implicitly. The set of patients who have talked about this mention it after they had noticed that they’ve begun to do it. In other words, they don’t sit down and intend to do it, but they begin to notice it. Just the way they gradually notice the way I’ve been talking to them, they later gradually notice how they have begun to talk to themselves or to other people.

RW: With a more empathic voice.

PW: Yeah. I’m often a critic of excessive explanations in terms of infancy because they contribute to the pejorative sometimes–described as pre-Oedipal and archaic and primitive and all that sort of stuff.

RW: Those are pejorative words for sure.

PW: Very much so. But if we think about the early attachment relationship, one of the things that’s interesting is that a parent’s interaction with an infant is almost completely about tone. It almost doesn’t matter what he or she says, because the infant doesn’t understand the words anyhow. But the infant does understand the tone, the feeling. So we develop very crucial skills in hearing the tone of others, which is part of what also is very central in good couples therapy, where the couple can have bad feelings keep reverberating between them. When you change the tone, good feelings start to reverberate.

RW: You give an example in your book: when therapist delivers an interpretation or comment without the accompanying meta-messages of acceptance or empathy, it’s like an organ transplant. It arouses the immune rejection by the body as if it’s foreign or alien. But with empathy, it’s not rejected. I call empathy the spoonful of sugar that helps the medicine go down.What are your thoughts about how this can be taught to therapists?

PW: Some of the teaching is explicit. Clearly, we need to articulate and point out that theory does have value. But some of it occurs through identification. With my students, as they hear my way of speaking and thinking, those for whom it’s not alien and rejected begin to take it in and make it theirs. What comes out in some ways sounds like me, but, very importantly, it also sounds like them. It isn’t a copy of me. It’s the aspect of me that’s of value to them, and they know implicitly what’s the kernel and what’s the husk.

RW: You were saying a minute ago that you were going to diverge from psychoanalytic thought, and we joked about being radical. That surprised me because 20 years ago I read, in a review of current issues in psychoanalysis, a segment along the lines that the optimal criterion of positive mental health in psychoanalysis has changed from autonomy and self-sufficiency to the capacity to interact with another person in ways that are mutually enhancing, and that analysts’ focus is shifting from accuracy of interpretation to quality of relationship. So I thought that was more or less widespread. Are you feeling like it is not widespread?

PW: I think you’re very accurately describing the direction of change in psychoanalysis. I, myself, identify very much with the relational point of view in psychoanalysis, and I’ve written from a relational point of view. And that point of view does embrace the very ideas that you were just mentioning. But when I wrote my book on relational theory and began to closely examine the relational thinkers whose ideas I felt fit well with mine, I also noticed that there were ways in which some of the older ideas continue to operate sub rosa, in a way that’s almost psychoanalytically validating in the sense that the early development of the field continues to influence it. The ways people talk about things explicitly is not necessarily the same as what is operating implicitly.It seemed to me that, for example, relational analysts who are increasingly the emerging dominant perspective in psychoanalytic thought operate nominally and explicitly from a two-person point of view, a point a view that emphasizes mutuality, reciprocity, the way in which we are both in the room co-creating the subjective reality, and so on. Those are the conceptual terms, and they are certainly a really important part of relational practice.

But

there are also ways in which relationalists continue to operate by the older one-person set of assumptions. They throw out terms like “pre-Oedipal” and “archaic” and “primitive” at almost the same rate that classical Freudians did.

The Old Guard

RW: It reminds me of meeting a couple in which the man was a psychologist. I knew that he espoused principles of nonsexism and egalitarianism, and yet his wife did everything for him, and his interactions with her conveyed, “I’m the superior one.”Are you saying these relationists who do not see how their language and behavior toward their clients contradict their values of reciprocity and mutuality are emotionally dishonest in favor of maintaining a superior position, or for some other unconscious emotional reason that has to do with the relationship to the clients?

PW: I think “emotionally dishonest” would be a harsher evaluation than I would make.

RW: You’re right. It’s like saying we’re dishonest if we see that the emperor has new clothes when he pretends he’s naked and we’re caught up in the denial.

PW: All of us as fallible human beings are struggling toward ideals that we don’t always reach. But I think there’s value in the struggle, and I think we can move ahead. For example, there are very real ways contemporary relational analysts do practice very differently from traditional analysts of several decades ago.But there’s still a way to go. And I’m sure, for example, in my own work, there’s still a way to go that I’m not recognizing. It’s inevitable. But I do think that the idea of something deep underneath that’s being hidden is a very seductive idea. To say that my relational colleagues might have some unconscious motivations for the particular positions they hold is not necessarily a criticism, because we all have unconscious motivations. It’s part of being human. You can’t not have them. That’s not the problem. The problem is when there are aspects of the way we’re thinking and feeling that don’t have a place to evolve and be looked at and experienced and integrated and modified.

If I have an experience that the patient is being emotionally dishonest–let’s say the patient is talking about his feelings about his wife, and I am hearing that there’s a lot more there than he’s willing to acknowledge–my role is not to point out to him his contradictions, his self-deceptions, his illusions. My role is to make room for the full range of his experiences so that he can examine them more fully. I would not be inclined, even in subtle ways–at least if I’m working as I hope to work–to point out his dishonesty. But I might say, “I’m hearing the ways in which you admire your wife’s achievements and feel that she’s misunderstanding you when she says that you’re being competitive with her. I hear that part of it. I’m wondering if there’s another part of the experience that you’re feeling isn’t acceptable, the almost unavoidable experience of also being envious or competitive with her.”

RW: With the word “unavoidable,” you normalize it.

PW: Exactly. And that normalizing is not a denial–it’s an invitation. It’s not a way of shutting out the so-called unacceptable. It’s a way of inviting it in.I think the other crucial word there is “also.” In workshops, I’ve sometimes jokingly said that your functioning as a therapist could improve 31.6% if you would just substitute one word for another. And I ask partipicants to guess what those words are. “Both, and” is one way, or “also” versus “really.” Often either saying or thinking, “What you’re really feeling is…” implies, “What you think you’re feeling is false.” I would suggest that if you think you’re feeling it, you almost inevitably, necessarily are feeling it. But you are likely also feeling some other things that are harder to acknowledge and harder to accept. So I switch from “really” to “also.”

Shaming

RW: In the examples you give in the new edition of Therapeutic Communication, there is particular sensitivity to comments that are inherently shaming. And you have a very attuned ear. It occurs to me that so much training, particularly psychoanalytic training, at least in my experience of it back in the ‘70s, was extremely shaming and challenging. I wonder how much of the tone-deafness to that note of shaming is part of the training experience and modeling–we want to talk to our patients the way we were talked to?

PW: The ways that we actually talk to people and the feeling tone in the room often follows more from the tone we absorbed in our own personal therapy and supervision. And that that’s one of the reasons that older ways of practicing and thinking persist even after the official position has changed.I also think, apropos what you were saying about what training used to be like and how it sometimes still can be, that for many years psychoanalysis was organized in a rather authoritarian way.

RW: That’s an understatement.

PW: Yeah. You had self-contained institutes with very little check on them. You had a hierarchical structure, you had training analysts, and you often had a kind of thought control: you would go into analysis, and until you got it right, which meant you got it the way you were supposed to think and feel, you wouldn’t even be approved to work with patients. That was a very problematic structure. It’s certainly been changing, but there’s still a long way to go.

The Gold Standard?

RW: Speaking of structural changes, and returning to your original metaphor of ethnic battles, what is the value for the tribal leaders of our profession to embrace the more integrated view of therapy you advocate for?

PW: That is a big problem. I think the only thing that, by and large, brings tribes together is an external enemy. The fact that our whole culture is being increasingly dominated by nonpsychological thinking altogether, by corporate bottom-line thinking, will hopefully be a spur to seeing what our common interests are.

RW: In the article you wrote recently, “Are We Prisoners of the Past?” you end by saying, “In the practice of psychotherapy, much harm had resulted from the efforts of therapists to help their patients achieve autonomy. Being able to stand alone is the false ideal of the culture of Ronald Reagan. Patients who benefit from psychotherapy are those who learn the lesson of mutuality, who move beyond both helpless dependency and the false ideal of independence. Mutuality and interdependence are the lessons we must learn on a social level, as well. Our fates lie in each other.”This seems germane to what you were saying about what the tribal leaders need. A common enemy can create a sense of mutuality against the threat. But also it seems like a recognition of the fact that security is higher if we are mutually interdependent. That’s certainly true internationally–if I have a bunch of factories in your city, I’m not likely to bomb it. So how can the tribal influences in current psychoanalysis, behavior therapy, and the others you’re trying to integrate, continue to not see this when it’s so reasonable, so obvious?

PW: I think all psychotherapists know that people don’t always see what’s reasonable.

A lot of our work is trying to figure out how to get people to see what’s plain as the noses on their faces, but not evident to them.

A lot of our work is trying to figure out how to get people to see what’s plain as the noses on their faces, but not evident to them. Often, whether it’s working individually with a patient or client, or trying to produce social change, it’s an uphill battle, and you have to be in it for the long haul. It’s one of the reasons that I also think the current corporate-promoted trend toward very short-term therapies, which translates into cheaper therapies, is often a mistake. Producing really meaningful change often takes a lot of effort, and it takes time.

RW: Along with these financial pressures, there’s also the increasing manualization of psychotherapy. What are some of your thoughts and reactions to that phenomenon?

PW: I have two different concerns about manualization. My strongest concern is that recently, when people have advocated criteria for demonstrating that psychotherapy is empirically supported, one criterion that’s often introduced is manualization. I think that that’s a very misleading and problematic criterion. It’s not that manualization can’t help in establishing what therapists are doing. But I’ve written in a number of places recently about some of the fallacies in requiring a manual as a criterion. One of the things it does is it creates a kind of caricature of science.Science is supposed to be about finding creating ways to empirically investigate phenomena, but the criterion of manualization defines away any investigation of nonmanualized treatments. In other words, if your treatment isn’t manualized, then by the empirically supported treatments criteria that have been propagated in recent years, it can’t even be investigated. Therefore, it’s dismissed by definition rather than through research. And that’s very problematic.

RW: Give me an example of some of those criteria that you object to.

PW: In the recently consensual (almost consensual, because I don’t consent and some other people don’t either) definition of what it means to be empirically supported, there are three things, each problematic, that are usually introduced. One is manualization. And the rationale for that is if we’re going to say that a treatment has been empirically supported, we have to know that was the treatment being administered. That much is reasonable, as far as it goes. But the problem is that manuals aren’t the only way to do that. You can, for example, have practitioners of a particular approach rate blindly a series of sessions, some of which are and some of which aren’t the kind of approach being investigated. And you can get high reliability, and that way you can investigate treatments that are not manualized and still establish whether that is the treatment being practiced. That’s one reason that manualization is a foolish criterion.A second criterion derives from a kind of false precision. The idea is that we look only at patients defined by a particular diagnostic entity. So if you have a general pool of patients and they get better, that gets dismissed because the claim is that’s a nonspecific finding. The irony of that is by and large the vast majority of advocates of this empirically supported treatments paragon are cognitive-behavioral. And for many, many years, cognitive-behavioral therapists were condemning psychoanalysis for being supposedly a medical model. And now, here you have CBT people embracing the psychiatric DSM–a committee-wrought set of categories that have little to do with empirical science–as if it were the Bible. And there’s certainly a medical influence: requiring a specific diagnosis and slicing people up that way is aping physical medicine, in which you need to distinguish diabetes from rheumatoid arthritis because you treat them differently. But most of what we work with as psychotherapists is not usefully or validly understood as a series of discrete diseases. So to introduce that as a criterion is very problematic.

RW: It’s the same reductionistic thinking everybody’s been yelling about for decades, but we can’t seem to get past it.

PW: Well, right now we can’t get past it because it’s politically useful for people who are advocating a particular point of view.

RW: You say that with a fraction of the anger that Thomas Szasz says the same thing.

PW: I don’t know how my fraction compares with his, but I can get pretty angry about what is happening these days.

Psychotherapy research is crucially important, but it’s got to be done honestly, and I think a lot of it these days, it’s not.

RW: In the last review I read of evidence-based treatment, which I think was John Norcross’s review commissioned by APA, the vast majority of the studies started at the beginning of the first session and ended with the third session. I just started laughing and dismissed the whole thing. I mean, we all know better than that. The forces that keep this model going are the desire not to know the truth, but to justify the status quo.

PW: And a part of that is this third illusory criterion, which is most seductive because there’s a lot that does make sense in it, but it’s, again, used politically rather than scientifically: the emphasis on randomized control trials (RCTs). That gets called the gold standard. Whenever I hear that, I like to think of the story King Midas, because turning everything into gold doesn’t always turn out well.I think here it’s a gold standard only under certain circumstances. For example, in the studies of drugs and medications that most psychotherapy RCTs are modeled after, one of the crucial elements is that nobody takes seriously a drug study that isn’t double-blind. Otherwise, the placebo effects are completely undetermined. In psychotherapy, it’s never double-blind. You can’t have somebody say, “We’re going to give half of you psychoanalysis five days a week and we’re going to give half of you an exposure therapy three times once a week. But we won’t tell which we’re giving.” Obviously, that’s absurd. People know what they’re getting, and people know what they’re giving.

So there, already, the RCT is overblown and misses something. But, more than that, in order to maintain the RCT, two things happen. One, the studies have to be very short term, because otherwise, the more it goes on, the more you have uncontrolled variables, which excludes what you can do research on.

RW: As if there are no uncontrolled variables in three sessions.

PW: Even in three sessions, they are an enormous number.

RW: Three minutes!

PW: Absolutely. And that’s, in fact, the other part of what’s problematic. Every psychotherapy offers us an opportunity to learn something. But if we are doing false homogenization and trying as hard as possible to give “the same thing” to each person in the group, we have very little opportunity to creatively learn from what we’re doing. And the crucial thing is that that’s not an anti-research view, at all.

RW: What advice you would have for a person who is working a clinic, hospital, or institution of any kind in which they’re being forced to adhere to evidence-based therapy, like the VA, where prolonged exposure therapy is institutionalized? The therapists don’t like it, but they have to do it anyway. What would you advise them to do besides quit their jobs?

PW: Social change is hard and slow, especially now that so many decisions are being made on an economic basis that secondarily justifies the psychological operation. So it’s hard to know what to tell them exactly. But the one thing I would say is that in making your case, understand really well the limits of the research that seems to support this truncated, limited, homogenized approach to things, because that research is very, very seriously flawed.

RW: It is. But what about all the research about the importance of the relationship? How does that factor in?

PW: That’s exactly the kind of thing that we need to emphasize. And this brings me back to why I was saying that I was not anti-research. I do think that because psychotherapy does create, almost instantly, a unique miniculture that evolves over time, it’s really hard for either party to understand or know fully what’s going on or to remember the sequences. You are recording this interview because if you try to reconstruct it a couple of hours after, it would be only a vague approximation of what’s actually going on between us. The same is true in psychotherapy.So I’m very much in favor of research based on audio- and videotapes that give us a database. But those tapes can be examined in the naturalistic process of psychotherapy, rather than in a homogenized, manualized treatment for one kind of research paradigm. There are a whole range of process outcome studies that teach us things that the other kinds of studies can’t teach us.

RW: You mentioned social change is slow. That reminds me of the curve of innovation, with the new innovators, and then the early adopters, and then the middle adopters, and then there’s the tipping point and everybody gets on board. It’s unfortunate that the new innovators are the people who were doing what the people did who discovered the importance of relationship 30 years ago. It’s the pendulum swung one way. Now it’s coming back.

PW: I think one of the problems in psychotherapy these days is that up until now, the people with the more narrowly mechanical ways of thinking have been more politically astute. And I think those of us who stand for serious research that addresses the true complexities of the phenomenon have got to do a better job of getting our point across.

RW: Tell us about your organization that you cofounded back in the 1980s, to create a forum for people who are interested in exploring the integration of psychotherapy. What are some of your goals, satisfactions, and frustrations?

PW: The name, Society for the Exploration of Psychotherapy Integration, is a mouthful, so we usually just refer to it as SEPI. It’s an international organization. It has members in 37 countries, and we meet all over the world. This May, we met in Evanston (Illinois). In 2013, we’re meeting in Barcelona.Our members represent all of the major orientations. We all have our identities as psychoanalysts or cognitive-behavior therapists or systems therapists or experiential therapists, but we also are interested in learning from each other and integrating other people’s ideas.

I thought of SEPI when you were asking earlier, “What do we do about this tribalism, and how can we get people to listen to each other and learn from each other?” It is hard within organizations devoted to a single point of view, because in those organizations, often the other points of view are experienced as Other.

In SEPI, there is no Other. There is a sense of coming and listening to each other. It is a place where we try to heal that breech.

I would be delighted if anybody reading this interview who was interested checked out the SEPI website, sepiweb.org.

I would be delighted if anybody reading this interview who was interested checked out the SEPI website, sepiweb.org. They can learn more about it from there.

Integration of Neuroscience

RW: One of the big new movements, with all the new technological advances in biochemistry, is the recognition of the connection between micronutrients and our brain’s capacity to make neurotransmitters that affect mood, thought, and behavior. How do you see that being incorporated into not only the integrative cultural, community, and interpersonal levels you’re talking about, but also in the intrapsychic and the physiological levels?

PW: I think we clearly are embodied beings. We’re not just abstracted minds. Anything that affects our bodies affect our minds. So all of our experiences at every level, whether they be cultural or nutritional, are part of this set of mutually reciprocal interactive processes that shape and reshape our experience. For example, if we think about the relation between psychological processes and neuroscience, neuroscience is only as good as psychology and vice versa. Mutual bootstrapping is the only way that we learn about, and even know how to look at, the differences between parts of the brain and what it means when one part of the brain lights up in a fancy fMRI study. Those lights are only as good as the psychological criteria that are showing what the lights are about.But that’s not psychological reductionism, because at the same time, the differences we see in parts of the brain lighting up can then re-attune us to notice differences in the psychological experience that we missed before, which in turn gives us still more refined tools for doing the next round of neuroscience studies. They keep going back and forth. It’s not just, “Neuroscience is the real thing and psychology is the surface.” They need to inform each other.

RW: The more we learn, the more we realize there are new unknowns.

PW: Yeah, and the more we can create new knowns. We keep building on both, as long as we’re not afraid of the unknown and we have the courage to acknowledge the known, in the sense of not having a kind of false modesty, but having the courage to say, “I’ve learned something. I know something.” On the one hand,

we need to be extremely modest as therapists. We need to be very careful about assuming we know, assuming an authoritarian position, assuming we understand.

we need to be extremely modest as therapists. We need to be very careful about assuming we know, assuming an authoritarian position, assuming we understand. That’s crucially important. But we also need to be able to acknowledge that we know something. When we speak to the patient in certain ways with a voice of authority, that’s the authority that just comes with having immersed ourselves in many lives in depth, and having been changed by that experience. We’re not just some new random element in the person’s life–we enter with some expertise. And if we can hold both our ignorance and our knowledge in tension with each other, then I think we can be more effective, more genuine, and more able to move forward.

The Miraculous (or not) Efficacy of Solution-Focused Therapy

Posted on June 6, 2012February 11, 2026 by Psychotherapy.net Team

For years solution-focused therapy approaches have been all the rage; the popularity of this distinctively brief therapy method is unarguable. Beginning in the 1980s, solution-focused therapy hit the mainstream and many mental health providers (and third-party payers) continue to sing the praises of its brevity and effectiveness. For example, in a 2009 book chapter Sara Smock claimed, “. . . there are numerous studies, several reviews of the research, and a few meta-analyses completed that showcase [solution-focused therapy’s] effectiveness.”

Solution-focused counseling and psychotherapy has deep roots in post-modern constructive theory. As Michael Hoyt once famously articulated, this perspective is based on “the construction that we are constructive.” In other words, solution-focused therapists believe clients and therapists build their own realities.

Ever since 2003, my personal construction of reality has been laced with skepticism. If you recall, that was the year President George W. Bush included 63 references to “weapons of mass destruction” in his State of the Union address (I’m estimating here, using my own particular spin, but that’s the nature of a constructive perspective). As it turned out, there were no weapons of mass destruction, but President Bush’s “If I say it enough, it will become reality” message had a powerful effect on public perception.

From the constructive or solution-focused perspective, perception IS reality. Nevertheless, as much as I’d like to ignore all evidence contrary to my own beliefs, I also find myself attracted to old-fashioned modernist reality—especially that scientific research sort of reality. Consequently, over the years I’ve often wondered: “What the heck does the scientific research say about the efficacy of solution-focused therapy anyway?”

Well, here’s a quick historical tour of scientific reality.

• In 1996, Scott Miller and colleagues noted: “In spite of having been around for ten years, no well-controlled, scientifically sound outcome studies on solution-focused therapy have ever been conducted or published in any peer-reviewed professional journal.”

• In 2000, Gingerich & Eisengart identified 15 studies and considered only five of these as relatively well-controlled. After analyzing the research, they stated: “. . . we cannot conclude that [solution-focused brief therapy] has been shown to be efficacious.”

• In 2008, Johnny Kim reported on 22 solution-focused outcomes studies. He noted that the only studies to show statistical significance were 12 studies focusing on internalizing disorders. Kim reported an effect size of d = .26 for these 12 studies–a fairly small effect size.

• In 2009, Jacqueline Corcoran and Vijayan Pillai concluded: “. . . practitioners should understand there is not a strong evidence basis for solution-focused therapy at this point in time.”

Now don’t get me wrong. As a mental health professional and professor, I believe solution-focused techniques and approaches can be very helpful . . . sometimes. However, my scientific training stops me from claiming that solution-focused approaches are highly effective. Although solution-focused techniques can be useful, psychotherapy often requires long term work that focuses not only on strengths, but problems as well.

So what’s the bottom line?

While in a heated argument with an umpire, Yogi Berra once said: “I wouldn’t have seen it if I hadn’t believed it!” This is, of course, an apt description of the powerful confirmation bias that affects everyone. We can’t help but look for evidence to support our pre-existing beliefs . . . which is one of the reasons why even modernist scientific research can’t always be trusted. But this is why we bother doing the research. We need to step back from our constructed and enthusiastic realities and try to see things as objectively as possible, recognizing that absolute objectivity is impossible.

Despite strong beliefs to the contrary, there were no weapons of mass destruction. And currently, the evidence indicates that solution-focused therapy is only modestly effective.

Cathy Cole on Motivational Interviewing

Posted on May 25, 2012February 27, 2026 by rezendevknowfully.com

Talking About Change

Victor Yalom: I think a good place to start would be to define and describe exactly what Motivational Interviewing is.

Cathy Cole: Motivational Interviewing is a counseling approach that has a very specific goal, which is to allow the client to explore ambivalence around making a change in a particular target behavior. In Motivational Interviewing, the counselor is working to have clients talk about their own particular reasons for change and, more importantly, talk about how they might strengthen that motivation for change and what way making that change will work for them. It’s a way for the counselor to guide a conversation toward the client’s goals, making the choices that are going to work for a particular person.

VY: I know the founder of this, Bill Miller, started in the field of addictions, where, at least for many counselors, there is a very different model of change, which is that the counselor needs to somehow break through the client’s resistance or denial about their drinking problem. In that context, MI has a very different philosophy.

CC: We really wouldn’t view that as resistance. In Motivational Interviewing, we’re listening very closely to what the client says and, more importantly, how the client is saying it. We’re listening for two kinds of language with clients: either sustain talk or change talk. What we might have considered resistance or what had been called denial in the past would actually just be consider sustain talk—reasons not to do something different, like reasons why stopping drinking would not be important, or reasons why, even if it’s considered important, the client doesn’t think they’re capable, or reasons why the client says, “I’m not ready to do this.”

VY: So in traditional alcohol counseling, for example, reasons why they don’t want to change are seen as resistance or denial.

CC: That was considered denial in the past. And it was viewed as the client not having paid enough attention yet to what the professional said they need to take a look at.

VY: So the professional is really the expert.

CC: That’s right. And in Motivational Interviewing, the client is considered the expert.

VY: Miller gives a lot of credit to Carl Rogers’s person-centered therapy in that regard.

CC: He does, and the basic conversational methods that are used in Motivational Interviewing came out of some of the client-centered work, particularly the use of reflective listening. When Bill Miller began to discuss this, he talked about the client being the expert. The clients are the ones who know themselves better than anyone else. The clients have strengths and capabilities, and clients have the ability to decide if making a change is important to them and why, and what would work best for them in terms of going about that change.

This is quite different from the traditional model of, “Here’s your problem. Here’s what you need to do. And if you don’t do it, that’s your problem, too.”

Of course, the counselor has an important role with this, because sometimes clients want to make change but they don’t really know how. So if, after fully exploring clients’ ideas about making change and what would work for them, the client still feels lost, we’re able to come in and provide some ideas for them to consider—things that we know have been helpful to other people or specific ways of approaching, say, stopping drinking. But ultimately, the clients are the ones who decide what they’re going to do. So this was quite different from the traditional model of, “Here’s your problem. Here’s what you need to do. And if you don’t do it, that’s your problem, too.”

VY: That’s the underlying philosophy of it, and then there are a lot of specific techniques. It’s very strategic, from my understanding. You mentioned one idea of sustain talk, and that is the clients telling you why they want to sustain or continue what they’ve currently been doing.

CC: Right. They’re telling you why they’re not going to do something different.

VY: When you’re hearing sustain talk, your goal is not to try to argue them out of it. You’re not trying to show them that they have some irrational thinking or beliefs. What’s your goal in listening to sustain talk?

CC: To me, there are two goals in listening to sustain talk. The first goal is for me to listen so that I really understand the client’s perspective and of why they are where they are with this particular behavior, and what might be interfering with them considering making a change. So I want to first really work on understanding that. And the way that I’m going to convey that I’m understanding that is by the use of reflection. The next thing that I want to do is to use various kinds of open questions to help the client completely explore the sustain talk, again, toward the goal of the client being able to make an informed choice about whether or not they’re going to change.

VY: And the other type of talk, to call it that, is change talk. That’s a really interesting idea, I think, especially for therapists. What is change talk?

CC: Change talk is when the client begins to shift and say that perhaps making change is important, or perhaps they are able to do it, or perhaps they are ready to do it. They begin to shift away from the reasons not to and they move into the direction of the reasons to make change, or the capability of making change, or that readiness to make change. And that change talk can be very subtle; it can be something that we have to really listen for. It may not be the dramatic, “Yes, I have changed my mind. Now I am definitely going to start losing weight or stop drinking or making a change in my drinking.” It could be as subtle as, “Maybe I should start thinking about that.” And the moment that that occurs, we want to then change what we’re doing in relation to that change talk.

VY: I know that Motivational Interviewing is used in a wide variety of settings, from addictions to healthcare, medicine, the criminal justice system. But just to keep things simple for now, let’s use the example of addictions, where it started. Can you give me an example of someone is struggling with drinking and give an example of sustain talk and change talk, and how you might listen for the change talk, and what you might do with it?

CC: The sustain talk might be something like, “My drinking is no worse than any of the other people I hang around with. In fact, sometimes I don’t think I drink as much as they do.” So that’s saying this is no big deal.A shift of that might be, “Well, when I think about it, I realize that some of the people I drink with actually do say ‘I’ve had enough’ and they quit. And I don’t always do that. Even if I feel like I’ve had enough, I just keep on drinking.” Many people might not hear that as change talk, but I hear that as change talk because the person is beginning to take a look at this and the drinking in a different way. I would really want to attend to that very carefully, and then help the client expand on that.

VY: How do you help them expand on it when you first hear that subtle shift?

CC: Continuing this example, my first response would be to do a reflection. I might say, “You’re beginning to pay attention to how your drinking pattern is not the same and realizing that there could be some pretty important differences.” I’m reinforcing the beginning of the client looking at this in a different way. By doing the reflection, that then provides the opportunity for the client to expand on what he’s beginning to think about.

VY: But you’re not jumping on it.

CC: No, I’m not jumping on it like, “Okay, so you really want to do something different,” because I’m just hearing the beginning of it. Again, MI is very client-centric, so I am helping the client move forward just a little bit, and I’m letting him now expand on this little bit of daylight that has started to show up here in terms of him thinking, “Maybe this is something I could look at in somewhat of a different way.” I want to help him move that along. But if I get too far ahead by saying, “Okay, so you realize that you have a problem,” the client will probably immediately push back to sustain talk because I will have gotten ahead of the client or really created some discord in the relationship at that point. So it’s very strategic in terms of how far ahead I’ll actually move.

VY: I know it’s a really important concept in Motivational Interviewing, for the therapist or counselor not to be the one arguing for change.

CC: Absolutely. The clients are always the ones that argue for change. We set the stage for them to be able to do that, should they want to, but they always present the argument for change.

VY: What is the rationale behind that?

CC: The rationale is if we have decided on our own that making a change is important, we’re far more likely to do it. And it’s also human nature that if someone else tells us that we have to make a change, even if we know we need to do that, we argue against it. We push back.

VY: So with this hypothetical client, say you reflect back the early change talk. How might it progress from there?

CC: Then the client says, “Yeah. I realize that if we go out drinking on the weekends, my other friends know that maybe they can drink a little bit more on a Saturday night, but when it comes to Sunday that they need to cut back and maybe not drink at all, or just have one drink. And they go to work on Mondays. I often don’t really slow it down. I continue to drink just as much on Sunday, sometimes maybe even a little more. And I sometimes don’t end up going to work. So I’m a little bit different than they are with my drinking.”To that, I might actually say a reflection back: “Your drinking takes on a life of its own. It actually gets ahead of you.”

VY: Okay, you summarize what they’re saying. You say you don’t want to get too far ahead of the client, but sometimes you might amplify their reflection?

CC: I’ll amplify that a little bit more. I took a little bit more of a step out this time, a little bit more of a risk, because the client actually started giving me more information. He started to have a different perspective. So I edged it out a little bit and really did a metaphor: “Your drinking has a life of its own, and sometimes it moves ahead of you.” I started to help the client really compare and contrast his drinking with other people’s drinking and just expanded, really, on what the client has said.

VY: It’s really a conversation between the two of you. The therapist does a lot of reflection and trusts that ultimately it’s the client’s decision whether they’re going to stop drinking, start exercising, manage their diabetes better, or whatever the behavior is. Does this tend to go on for a long period of time throughout a course of counseling? Is it very focused on a specific behavior?

CC: Motivational Interviewing the way that we’re using it is focused on a particular target behavior. It’s something that the client is talking about with a sense of, “I need to figure out how to deal with this.” Motivational Interviewing is actually considered a somewhat brief way of working with people in that the person is deciding whether they’re going to do something and then what they’re going to do.Let’s say the drinking from our earlier example is the target behavior. The client decides over the course of a couple interviews that this is a bigger deal in life than he had looked at before, so he’s saying, “Now I’m going to do something about this.” Now we’re getting a clear message of, “Yes, I want to move ahead.” So we begin to take a look at how capable the client feels of doing something about this and what it is he wants to do.

Let’s say I’m an outpatient therapist and doing a specific alcohol treatment is not necessarily my strong suit, but I have this client who comes in and that’s what the client wants to explore. It could be that in the course of that conversation, the client decides, “I’m going to do something about this. I’m going to go to a specific center or perhaps even an inpatient program that deals with alcohol problems.” Or let’s say that it’s a brief intervention to help the client get to the place of saying, “Yes. Now I’m going to do something about it,” and then he moves into planning how he’s going to do something about it. That might mean that the person moves away from me and that I’m not working with him any longer.

But let’s say that I am comfortable working with an alcohol problem. So now we have resolved that initial ambivalence. We’ve moved toward, “Yes, this is what we’re going to work on together.” At this point, we’re going to be working with whatever the client needs to take a look at: for instance, is he planning to try to moderate, or is he planning to try to stop altogether? If he’s going to stop altogether, what do we need to address with that? What might be barriers for him in continuing to maintain abstinence once he’s established it? So we’re not into the nuts and bolts of how he’s going to do it. I’m still not telling him what to do, but I’ve shifted away from that first part of Motivational Interviewing, which is just to resolve that ambivalence about doing it in the first place.

But let’s say that client is continuing along in therapy and with this change plan, and couple of months down the line, the client now says, “I don’t know. Maybe I don’t really need to continue to do this any longer.” So now we’re just going to explore that again. I’m always listening for where the client might become uncertain about continuing to work on this particular behavior. Then we’re going to come back and use Motivational Interviewing to work with that ambivalence.

Stages of Change: Importance, Ambivalence, Confidence

VY: Coinciding with this interview, we’ve just completed a series of Motivational Interviewing videos with you. The first one lays out the general principles, and then the next three address different stages in the change process. It’s an interesting way of thinking about the process of change in general. The first one deals with the idea of increasing importance. Can you just state briefly what is meant by that?

CC: When we talk about increasing importance, we are basically talking about the client’s buy-in around making change. The client has to decide, “Why is this an important issue for me in the first place? Why is it important for me to take a look at the role of drinking in my life? In what ways might it be creating problems for me? In what ways would taking a look at this and making some changes enhance, perhaps, parts of my life or what difference does it make for me to actually control my diabetes when I’m going to have it forever anyway? Why would I stop smoking? Why would that be important?” That’s the first thing when we’re talking about making a change. First, we have to believe that making the change is important, because if we don’t believe that it’s important to make a change, then we’re really not going to do anything.

VY: So first the client has to at least consider that it is important for them to change. And even when they consider it’s important, the idea that they might change is often counterbalanced by inertia or sustain talk—they still might be ambivalent about actually going ahead with it.

CC: Exactly. If we think about it, probably one of the most common questions that the majority of people deal with is, “Is it important that I eat in a certain way so that I maintain the health that I currently have? Is it important that I have a regular exercise routine?” And a lot of times, clients don’t actually realize that it is important for them to make a change.Let’s take an example of a client who has had a yearly physical with routine screenings, lab tests, things like that. The doctor points out that some of her lab values are off. Let’s say liver enzymes are off or cholesterol is high. The client has really not even considered that she needs to make any kind of a change, and now the doctor is saying, “These are indicators to me that you should take a look at these things in your life—that you should take a look at your diet, you should take a look at your drinking, you should take a look at the use of exercise to have an impact on these particular health issues that I have a concern about.”

VY: So this is all new information to the client. For the first time, she thinks, “Gee, maybe it’s important that I make some lifestyle changes.”

CC: Exactly. And other times clients have sought counseling about something that they think might be important, but they’re not sure yet. So they’ve come to sort that out for themselves. Or perhaps someone is saying, “I’ve really always identified myself as a person who speaks my mind. I want to express myself honestly, but I’m beginning to get some feedback at work from my boss that that is really not going to help me advance in my career. So I’m thinking maybe I should take a look at that, but I’m not so sure.” So he’s trying to figure out if changing something about the basic way that he has been interacting is important for him to work on.Or perhaps a young mother has been following the ways that female relatives have been telling her she needs to be dealing with her newborn baby, but she’s read some literature that maybe that’s not quite the right thing. So she wants to talk to the baby’s pediatrician about whether or not she should do something different, because she’s getting conflicting information.

VY: We’re moving into territory where the client is aware that there’s some potential need to change, reason to change, but they’re ambivalent. There might also be a reason not to change.

CC: Right. It’s so much easier to do things the way that we’ve been doing them all along. In the case of the young mother, it could be that going against the grain of what she’s being told by these other significant people in her life is something that, while she might think it’s important, maybe she doesn’t think she can pull it off. Maybe she thinks she’s not really capable of standing up to them and saying, “I’m going to bring my child up in a different way,” so it’s easier for her to say, “No, I don’t think it’s that important.”

VY: Throughout the course of counseling, assume you resolve this ambivalence in one way or other and the client decides, “Yes, I do want to cut back on my drinking,” or, “I want to quit my drinking,” or, “I want to lose some weight.” Then you move into the territory of whether they have the confidence to make that change.

CC: Exactly—whether they feel that this is something that they’re capable of actually doing. And if we look at, say, people who have decided that they want to stop smoking, many, many people can say, “I know it’s important not to smoke, but I have tried and failed so many times to stop smoking that I’m just not sure that I can actually do it. So maybe I should just keep on smoking because I really don’t want to fail again.” Now we’re now helping them take a look at the issue of confidence and capability.

VY: What is MI bringing to the table there? How do you help increase someone’s confidence or likelihood of making that change?

CC: One of the things that I would do is explore with these people any past attempts that they’ve had. If they’ve had any success at all, even if it’s just been for a day, I’d like to find out what helped them, or what happened that they were able to be successful even for a short period of time. I’d also want to explore with the person other areas in their lives where they have actually tackled some sort of challenge or made a change successfully, and help them talk about what helped them be successful at that time. Perhaps it was outside support from another person, or it was buddying up with a person to be able to pull off an exercise routine.I also help them determine what natural traits and characteristics they possess that help them tackle things in life that could be difficult, and how could they use those particular traits to help them in this particular area.

Another thing that helps with confidence is actually giving people sufficient information about how they might go about making this change, and helping them explore whether or not they think that would work for them.

Most of us are not going to step out into making a change unless we think we can pull it off, so to actually have an idea of how to go about it can be very helpful.

Offering Advice and Information

VY: As I said, Motivational Interviewing is widely used in healthcare and medicine, although our audience for this interview is mainly counselors and therapists. I think it’s just important to note that, say, in a medical setting, a healthcare provider might have very specific information about managing diabetes or quitting smoking. But also in counseling, if we have particular expertise in addictions, again, we might not tell them what to do, but we might say, “Based on our experience, this is going to be more likely to be successful than this.”

CC: If a person is saying, “I want to do this, I just don’t know how, and therefore I’m not confident,” we might say, “If it’s okay, I can give you some information on what has been helpful to other people, and from there we can see what you think about that in terms of it being useful for you.” I might present two to three ideas, then stop and go back to the client and explore again. “What do you think about that?” And see how they would work with that.So in addictions, I might say, “Some people find it helpful to do things like 12-step recovery and others find it helpful to go to specific treatment kinds of programs, while still others use things like web-based programs to help them deal with establishing abstinence and getting support. Other people have turned toward their faith, if that’s been something that’s important. So I’m just wondering, out of some ideas that I’ve presented, what ideas that brings up for you or what other questions that you might have.”

I’m always coming back to the client and checking in again, because ultimately the client is the one who’s going to decide.

VY: That again, is quite different from an approach where you say, “You really need to go into an inpatient program.”

CC: It’s very different from a prescriptive approach. I want to make sure, though, that folks listening to this don’t misunderstand: the counselor can actually provide specific recommendations, but it’s done in a way that ultimately our clients still know that they are the one making the choice. We’re reinforcing our clients’ autonomy.Let’s say that I have done an assessment with someone in relationship to drinking patterns and what kind of impact drinking has had in this person’s life. And let’s say that the client is now trying to decide whether or not he wants to do some harm reduction, or whether he wants to be completely abstinent. The client might ask me what I think, and it’s perfectly okay for me to give my point of view, but I would say it perhaps in this way: “Ultimately, you’re the one that’s going to make your choice. But from my review of your history and from what I hear about you trying to do moderation in your past attempts, it looks for me like going for abstinence is the right thing for you to do, certainly at this time. That’s my professional recommendation based on what I learned from your history. But again, I want to know what you think about that. Ultimately, you have to make the decision.”

What’s New About MI?

VY: It sounds very consistent with how a lot of therapists work in general. We generally don’t tell the client what to do. We think that we’re listening to them and being supportive. For the therapist who wants to integrate this into their general work with clients, what’s most new about this? When you are training counselors, what do you find really stands out for them about this approach?

CC: Particularly with seasoned counselors, what stands out as new for them is listening for when the client becomes uncertain again about addressing their target behavior—when they begin to shift and begin to have some doubt, perhaps, that they are capable of doing this or that it. It remains important to listen for that and realize that when we begin to hear that, we now need to shift and start to explore that uncertainty again and not act as if we’re continuing to move forward, because then we’re not really in sync with the client any longer.

VY: By that, you mean the client has been exploring the possibility of change but then hit a roadblock and start to get stuck back into ambivalence.

CC: Yes. They go backwards. They shift directions and move back into sustain talk. Let’s stay with the drinking example: say your client has decided that he wants to establish abstinence and he’s done that, and he’s been abstinent for three months and continued to work on possible barriers in supporting that.Then he comes in one session and says, “I’m doing really well with this, but I’m beginning to think that I just needed a break. I just needed to stop for a little while. I could probably go back to drinking again.” So he’s shifted directions. He’s said, “I’m thinking about this in a different way” which means that we have to now shift and begin to explore what’s happened and see where they want to go with this. Perhaps he has decided that the break is what he’s had and now he would like to try harm reduction or moderation. So now we’re attending to this in a new way.

VY: And the therapist needs to watch out for that tendency to want to kind of jump on the client, saying, “But you already decided this.”

CC: That’s exactly right.The temptation is to come in and try to convince the client, “You’ve made this decision. You shouldn’t turn back. You should keep going with this decision.” But then we will have moved into a position with the client where we’re not partnering with him any longer. We’ve decided that we’re the expert and we’re going to tell him what to do.

The other thing I think is new, in terms of really attending to it, is this difference between sustain talk and change talk. Motivational Interviewing really emphasizes that in a way that other counseling approaches doesn’t, and we’re really explicit about this. I find that this is new territory for counselors, to think about client language in this way.

In the years that I have been doing training, I have found that it’s challenging for people to pick up on change talk and to reinforce it. Counselors have to really start to tune the ear to pick up on change talk, to notice when that occurs and then shift direction and actually start to reinforce that change talk. Counselors often know the good client-centered skills, as you have mentioned. But listening for that change talk and beginning to reinforce that is often novel.

I think there’s something about us as therapists, and I think it’s our desire to know, and to know more detail. We get really seduced by the detail. We want to keep hearing more about the why-nots that are on the side of sustain talk. Our curiosity about knowing everything on that side of the world gets us in trouble sometimes, because when that change talk occurs, we really need to abandon everything that has occurred up until that time that has to do with sustain talk, and move ahead. It doesn’t mean that we don’t come back later and explore some of the barriers that the person might have talked about. But we do that once we’ve moved ahead and we’re saying yes to change. Now we may look at what gets in the way. But actually hearing the change talk and, when we hear it, immediately moving with it, can be a challenge.

VY: One way I’m hearing what you’re saying is, as therapists, we often like to look at people’s struggles and how they get stuck. It reminds me of an interview we did with Martin Seligman on positive psychology and psychotherapy, where he said that most traditional psychology is focused excessively on pathology and not giving equal focus on positive factors, on our strengths. So I’m thinking of it in that light, that therapists may get stuck on wanting to explore people’s challenges and problems and not give equal weight to hearing about people’s motivations for change and exploring that equally.

CC: I think you’re absolutely right. And in some ways, I think our initial training may have set us in that direction. To look at the positive side of this for us, we are really good at sitting with the struggles that a client has, at being able to understand it. And sometimes I think that strong capability that we have in that area might get in the way of us hearing those subtle changes of, “I don’t want to struggle this way any longer.” So we have to be very tuned into that.

VY: And sometimes therapists think, “Well, if you’re moving into just supporting them to change, that could be superficial.” I’ve seen you work, and I’ve seen videos of Bill Miller as well. And what strikes me is it sounds simple, but to do it well it’s really very nuanced. It’s very subtle and very strategic.

CC: Yes, very strategic. And there’s nothing more exciting to me than to have a client begin to embrace the changes possible and begin to believe in the capability that they can have in making that change and just watching that deepen. That, to me, is an extremely exciting thing to see happen. And I’ve equally seen the same thing when a client is with a counselor and they have started to say, “I’m really tired of talking about why I wouldn’t change. Now I would like to talk about why I would change and what I’d like to do about it.” When the counselor doesn’t listen to it, the light goes out of the client and the interview. It’s like the client gives up. So it’s a very special way of working with people, to reinforce client autonomy and to realize the extremely valuable role that the therapist has in guiding this process. If clients already knew what to do to make change, they wouldn’t be sitting in our offices in the first place.It’s very rewarding to work in this way and to watch clients become excited about themselves and what they can do. They often will say, “Thank you so much for telling me what to do,” when we’ve not said anything about what to do. They’ve come up with those ideas themselves, but they kind of think that we have. It’s a very fascinating thing for me to watch, and I often will say, “No, you’re the one that came up with that. I didn’t tell you what to do at all. You came up with that idea.” But they appreciate the process.

VY: Again, the counselor or the therapist has expertise in the process of change but they’re not the experts on clients’ lives and what clients should do to live their lives.

CC: That’s exactly right. Our role is to help our clients figure that out and to put words to that, so that they can really solidify that and deepen it.

MI with PTSD

VY: You work in the VA, where of course they’re very concerned about treatment being effective and using empirically validated approaches. I know there’s been a lot of research on Motivational Interviewing. Are you familiar with the research?

CC: I’m familiar with the research on Motivational Interviewing. There’s lots of evidence that clients make more changes in whatever the target behavior is when Motivational Interviewing approach is used rather than some other standard approach. Motivational Interviewing has a specific niche, and that niche is resolving ambivalence to change. I can give a brief example of how I use that in my work.I work with folks who often have had long histories of problems related to trauma, particularly sexual trauma in my line of work. They have posttraumatic stress disorder and have developed a number of behaviors, primarily avoidant behaviors, to help themselves feel safe in the world. And at some point in time they’ve come to my office, either self-selected or by a referral from someone else in the hospital, because they’ve screened positive on a PTSD score or they’ve said something to their doctor, and the doctor has encouraged them to see me. So now they’re in my office and we’ve done some history. We’re now at the place of the client deciding, “Am I going to do something about it?” The target behavior is this avoidance behavior, perhaps, that’s come from the PTSD, and clients now have to consider, “How important is it for me to actually do something about this? What’s that going to mean for me and my life? Am I willing to go through what might be a painful process to address this? Am I willing to face these fears in order to make some changes in my behavior?”

I’m using Motivational Interviewing at that point toward clients letting me know yes or no. “Am I going to work with this or am I not going to work with this?” That’s the engaging, the focusing, and the evoking part of Motivational Interviewing processes that we use.

Let’s say a client comes to a clear yes: “I really need to get on top of this because my 25-year-old son is saying to me, ‘I won’t leave home until you are less fearful,’ and it’s not okay for me to hold my son up in his life.” So the importance is not based so much on what the client wants for herself; it’s based on what the client wants for that son. It’s a clear value issue around the son. The client is now saying, “Okay, I’m willing to do this because it would benefit my son. And perhaps I’ll get some benefits, too, but it’s really so I don’t hold my son up in life.”

Now I have a clear yes, and we’re going to move into talking about the possible ways that this client can actually go about doing this work. And that’s where I can then present the evidence-based therapies that are available, either through me or through our institution, so that the client can then decide which of those evidence-based therapies she will use. So I have done the first task of Motivational Interviewing, which is resolving ambivalence, and now the person moves into some other specific form of therapy.

VY: Which you might provide or someone else might provide.

CC: Exactly. I can then review what we currently offer. I’m still using Motivational Interviewing because I’m letting her know the possibilities, and then she can decide from those possibilities which one do she thinks she would like to try, what might work best for her.

VY: It’s a nice example because it shows how you can integrate MI into a traditional course of therapy and also shows how you can use it with a problem. It’s not as circumscribed as a drinking problem or a specific healthcare issue. It’s a psychological problem that results from PTSD and fear. But it’s circumscribed enough that you can use MI to decide whether or not a client wants to tackle it or not.

CC: Right. So then the client has made a clear, informed decision. I continue to talk about Motivational Interviewing as informed consent. The client is thoroughly exploring the issue and making the decision, and that’s informed consent.

Teaching MI Skills

VY: Another thing that’s impressed me about it from what I’ve heard primarily from you, Cathy, is the training in Motivational Interviewing is very detailed. A lot of training in our field is more theoretical or overview focused, but from what I understand, to be certified in MI or as a trainer, people really look at your work and you get very specific feedback.

CC: Right. I always speak to the certification issue. There’s no particular certification process for people learning Motivational Interviewing, but many people go through training with folks like myself who provide training in MI. And it’s not just coming and sitting through a lecture; it very much involves practicing all the parts of Motivational Interviewing. Then, working with a person who can provide feedback and coaching by actually listening to interviews is what increases trainees’ competency in using Motivational Interviewing.

VY: When you’re listening to someone’s interview, what are you listening for?

CC: Actually, there’s a particular scoring guide that many of us use who provide coaching and feedback. I’m listening for whether or not the person is using what we call MI-adherent behaviors, using open-ended questions, using a higher reflection-to-question ratio, avoiding telling the client what to do, working fully to understand what’s happening with the client’s point of view.We’re listening for whether or not the therapist is keeping the focus on the direction in the interview; focusing on the target behavior, helping the client fully explore and understand the current issue, allowing the client to explore their own ideas about change, and helping the client deepen the meaning of making change.

There are many counselors who are very good at guiding the direction of an interview. They can keep a client on target. But they don’t necessarily do very well at exploring the client’s understanding, exploring the client’s own ideas for change, really validating. They might hear a client’s idea and immediately say, “Yeah, that’s a good idea, but let me tell you a better one.” That statement is completely non-adherent.

We’re listening for all of those things in an interview and providing very direct feedback on what the counselor’s doing. We know that the only way to really develop skill in Motivational Interviewing is to get feedback.

VY: I think we’ve really covered a lot of material here, at least to introduce people to some of the core concepts of MI. If folks are interested in learning more, where would you direct them?

CC: There’s the Motivational Interviewing website, and trainings are listed there. I certainly provide training myself. The trainings that I provide throughout the year are all listed on my website. There are a number of trainers who provide workshops throughout the United States. It’s also possible to engage a trainer to come to an area and provide a two- to three-day training for a group of people that someone organizes locally. So there are a variety of ways to go about getting training.

VY: You’ve been training therapists and counselors in MI for a long time. How have you evolved personally in your understanding and skills?

CC: Yes, I’ve been practicing Motivational Interviewing since 1992 or so, and I’ve been training since 1995. It’s changed me as a therapist very much in terms of my ability to listen, to not judge the client, to really be accepting of the client and the struggle that the client is bringing to the table. Again, that’s basic Rogerian counseling, and it sounds simple. You can spell out the principles in a couple sentences. But it’s very subtle and it’s not easy to do.

VY: Are there gradations in that ability to accept clients where they’re at? Do you see yourself doing that more, better, deeper now than you did 10 or 15 years ago?

CC: Yeah, I do. I think that when I became aware of Motivational Interviewing and I began to learn the very specific ways to have a conversation with a client using MI methods, I became even more aware of the strengths that clients bring to the table, and I became even more appreciative of clients knowing what is right for them, when it’s right for them, and accepting choices that clients make, whether or not I thought they were the right choices for the client or not.

I feel calmer as a therapist working in this way. I’m not disengaged from the process or detached from it at all, but I’m fully appreciative that responsibility for change lies with the client and that I have a very important role to help that client fully explore this possibility, but that ultimately, I’m there to respect the decision the client makes. It’s a very refreshing and calming way to work. I think the feedback from clients really reinforces that for me. It’s not a struggle.

Motivational Interviewing in End-of-Life Care

Posted on May 25, 2012February 11, 2026 by rezendevknowfully.com

Betty: A Case Study

When Betty answered the door and welcomed me into her living room, I couldn’t help thinking she looked almost like a different person from the Betty I’d seen just the day before: a neatly dressed, very composed 80-year-old woman. Today, her clothes were messy, her hair was disheveled, and she had bags under her eyes. Her husband, Frank, was resting in their room after his morning nursing visit. He had been diagnosed with prostate cancer a year earlier, and the treatment had been unsuccessful. The hospice team of which I was a member had been called in to assist with the final few days of his life, which is why we had met Betty and Frank the day before.

The nurse, spiritual counselor, and I had visited the couple in their home, as this was where Betty and Frank preferred for him to pass away. During the initial visit, Betty had engaged appropriately, was very pleasant and cooperative, and asked common questions about what to expect in this process. She had hired a caregiver for further support. She seemed to be coping well and had a strong supportive network with her children and neighbors. Frank had been a bit lethargic, but was able to engage with us as we discussed his care over the next few days. The visit had gone smoothly; we hadn’t expected any unusual problems.

But the morning after the initial visit, the nurse called me explaining that she had completed her daily visit and Frank had declined significantly overnight. He had been very lethargic and difficult to arouse during her assessment. Betty had asked the nurse if she could feed her husband, since he had only a few bites of food at dinner the night before and had not had breakfast. The nurse had informed her of the risk of feeding when a patient is closer to death, but felt that Betty was very resistant to this information. The nurse was calling me to ask if I could meet with Betty to address this resistance.

As a social work intern, this would be my first meeting alone with a client. As I was simultaneously enrolled in a graduate course on Motivational Interviewing, I decided to put my beginning skills to use.

Engaging the Client

I began by checking in with how Betty had been feeling since our visit the previous day.

“I feel good,” she said, “but I had a hard night last night with Frank waking up several times. He was moaning and confused, and even tried to climb out of bed. It really scared me, but I was able to call hospice and they walked me through giving him some medication to calm him down. It worked quickly and I was able to get some rest for a few hours.” She paused and touched her forehead absently. “I’m glad to have our caregiver here this afternoon so I can lie down and get more sleep. She was so helpful yesterday.”

I remembered from my MI course that open-ended questions, affirmations, reflections, and summaries (OARS) are key to building rapport and conveying empathy and understanding. When clients feel heard, they are not only more inclined to engage with the practitioner, but they are also more comfortable processing their ambivalence, and eventually reaching a resolution. I knew that Betty had had a fraught conversation with the nurse that morning, and that she must be feeling overwhelmed, so even though we had limited time, both in the session and in terms of Frank’s life, I began slowly.

“Wow,” I said. “It sounds like you had a difficult night caring for him. Caregiving for someone in the dying process is challenging. I’m really impressed that you’ve been doing this, while also recognizing you need some help and have hired a caregiver. I’m glad you called our main line for support, too. We’re always available to help.” The simple reflection and affirmation I used helped us start the visit well. Betty knew I was present and listening to her. I was also able to validate and affirm the challenges of providing caregiving at end-of-life and how well she was doing.

“I understand you met with the nurse this morning,” I continued, now that I saw Betty relaxing a bit in my presence. “How did that go?”

Betty paused and her voiced dropped. “Fine. She told me I should stop feeding my husband, but that’s hard because he could be hungry.” She paused again and then raised her voice. “She said that feeding him could hurt him, though. I’m not going to be the one to kill him!”

I reflected that Betty felt confused about what the nurse had told her about feeding.

Betty raised her voice again and spoke more quickly. “It’s really confusing. And it’s like she doesn’t really understand where I’m coming from.”

“She doesn’t see how much you value feeding Frank,” I nodded.

This exchange confirmed for me that Betty was struggling with understanding and accepting that her husband no longer needed to eat or drink as he was declining quickly. As the nurse had explained to her, feeding him would have likely caused more harm because as his body declined, it would not metabolize food and fluid as well, which could cause increased toxicity, pain, and discomfort.

Given the medical nature of this information, and especially because of the urgency of the situation, with Frank having only a few more days to live, it would have been tempting to believe that Betty’s inability to understand could be solved by intellectual persistence: maybe if someone explained the details to her again, she’d “get it.” But using an MI framework, I saw clearly that Betty needed to be met emotionally in her struggle before she could comprehend the medical problems that continuing to feed her husband would create.

In situations where there is a clear preferred outcome, it is often challenging for counselors and other helping professionals to steer away from what in MI is called the “righting reflex,” the temptation to tell the client what is best for her and what she ought to do. But this technique does not support client autonomy or self-determination, and defies the MI belief that the client is the expert. It also tends to pit the client against the therapist as an adversary or an authority against which to rebel. Telling Betty to stop feeding her husband could have caused her to shut down and damaged any trust she had in me that I understood her situation. Furthermore, the righting reflex may have robbed Betty of the opportunity to process her loss.

Change Talk

It is important to note that Betty acknowledged that she heard that feeding could be harmful and even said, “I don’t want to be the one to kill him.”

MI emphasizes two concepts called “sustain talk” and “change talk.” Clients engage in sustain talk when they discuss the status quo, or give reasons why they cannot make a change. Betty had been engaging in sustain talk thus far in our conversation, going through her reasons for believing she should continue to feed Frank. Change talk, which is any mention of change as a possibility, marks a client’s willingness and preparedness, however slight or tenuous, for change. A clinician using MI should emphasize and explore a client’s change talk through reflections and open-ended questions. This allows the client to focus on change rather than maintaining the status quo.

Betty’s statement that she didn’t want to be the one to kill her husband identified her ambivalence and was an example of change talk. It let me know that Betty was open to exploring the possibility of refraining from feeding her husband in this final stage of his life, though clearly she had not yet reconciled herself to this option.

Before we examined the change talk, I wanted to reflect Betty’s ambivalence and confusion while stressing how much Betty loved her husband and wanted nothing more than to give him the best care possible. “You’ve really taken on the role of being his caregiver and part of that role is feeding,” I began gently. “The way you see it, just because he’s at the end of his life doesn’t mean you should stop that role now. And as you said, he could be hungry.”

Betty sat forward in her chair. “Exactly!” she exclaimed.

Sensing I had struck a chord with her, I continued. “You also said that you heard the nurse explain that feeding could be harmful.” Here I was able to focus on both sides of the issue: one the one hand, feeding was part of her role as caregiver, and on the other, she was aware that it was risky and could likely cause more harm, which she didn’t want.

“Yes, but I don’t really understand why,” Betty said, her voice heavy now, and she slumped back in her chair a little. “I know if people don’t eat, they die, so I don’t want to have that guilt that I’m not feeding him and he dies. He’s my husband, and I want to do the best job I can.”

Noting that Betty was moving back into sustain talk, I continued with affirmations and reflections to build a sense of alliance. “You have taken excellent care of your husband, and your family, for the sixty-four years you’ve been married. Feeding is not only part of caregiving, but also a way you show your love for him, which is something I definitely understand. It sounds like if you stop feeding him you’re scared that it could hasten his death, which would make you feel guilty, like you’re responsible for him dying.” I was able to use this complex reflection—drawing on Betty’s implied statements and feelings as well as the words she spoke—to assign meaning to the feeding, explore the sadness of her changing role as a wife, and allow her to process the fear of hastening her husband’s death.

“Yes,” said Betty. “I’ve taken care of everything all these years. The cooking, cleaning, laundry, shopping. And he likes that I do those things. I want to take the best care of him all the way until his last breath.”

I affirmed her role by saying, “Something I’ve seen from you in the times we have met is that you are a very dedicated, loving wife, who wants nothing more than to care for your husband, especially at the end of his life.” I began to understand that Betty’s roles as wife and mother were not only central to her relationship with her family, but also to her personal identity. Although cooking and her other activities seem like minute household chores, these activities were how Betty showed her love for her husband and children. If she was no longer feeding, how could she express her love, especially at this most intimate time in life?

As I reflected Betty’s deep desire to provide the best care to her husband in his dying process, she became tearful. “I’ve cared for him for so long,” she said, “and I’m feeling very overwhelmed about this. I just can’t believe he’s dying. We’re high school sweethearts. I can’t remember life without him.”

I could really empathize with Betty in that moment. Although she had been able to understand intellectually that her husband was terminal, the emotional impact of the dying process weighed heavily on her. Thinking about what her life would be without her husband was devastating. “This experience has been really difficult and emotional for you,” I said. “It’s hard to even imagine life without him.”

With tears filling her eyes, all she could say was, “Yes.”

Ambivalence, Not Resistance

I was sensitive to not push her too far. We still needed to address the feeding, and if she became overwhelmed with grief, it would have been inappropriate to have that conversation. So I continued to affirm her. “I see just from listening to you that you and Frank are so incredibly in love and have been for a long time. You’ve created an incredible life together, have two wonderful children, three beautiful grandchildren, all are an extension of you two and represent your life and your love for each other.”

Reflecting on the lives patients and families have shared is a vital component in helping them experience a peaceful death with dignity. Processing their lives affirms they were special and facilitates closure. Here, affirming Betty’s desire to continue providing loving care helped her to feel understood and acknowledged. My acknowledgment of the specialness of her bond with Frank seemed to calm her down a bit.

I decided this moment was the opportunity to provide some education about Frank’s state, but first I needed to ask permission. Asking permission is essential in MI because it gives the client control of the session. In a careful tone I said, “Maybe if we could clear up some confusion about the feeding, then that could help you feel a little better and assured that you are taking the best care of Frank. Would it be okay if I shared some information with you about feeding at end-of-life?”

“Yes, I’d be okay with that,” said Betty. “The nurse just didn’t explain it to me well.”

“I can understand,” I said. “Sometimes we think it’s clear because we have this discussion often, but the family needs a little more education and I’m happy to provide that.”

“Yes. I just cannot understand how eating could be harmful.” She had become quite agitated again, her shoulders tense and limbs tense.

Maintaining a gentle tone, I explained, “It seems very unclear because when the body is healthy, it needs nutrients from food. As a person gets closer to death, the body doesn’t need the same amount of nourishment as it did when it was healthy. The body slows down and its metabolism slows down, so the food cannot be broken down at the same speed as when the body was healthy. Now that Frank’s body is slowing down, he can’t digest food in the same way, so the food and liquid gets kind of stuck in the body, causing more harm than good. I know that sounds strange, but does that make sense?”

She seemed puzzled. “So he can’t break down the food?”

“Exactly,” I told her.

I was becoming hopeful that Betty was beginning to understand the risks of feeding and we were about to make a break in resolving her ambivalence. But then she responded, “Well, what if I just give him less food?”

I suppressed a twinge of impatience. That question made me see that she was still unsure and possibly resistant to stopping the feeding. But although resistance can sometimes be frustrating for practitioners, an MI practitioner always rolls with the resistance and should avoid the righting reflex in times of client ambivalence. Betty’s question was simply her way of expressing that she was still unsure what was right.

Resisting the urge to use the righting reflex, I calmly said, “Well, sometimes that can be okay, but if the food is not soft and thick, there is a risk that it could go into his lungs and he would aspirate. That could cause an infection and actually hasten his death.”

My hopes that this education would help move discussion along were quickly halted when Betty said, “Oh. Well I’m glad to know this, but even if I gave him just a little, it couldn’t hurt him that badly, right?”

A Circuitous Route to Change

I was unsure how to move Betty out of her now entrenched sustain talk. Betty was trying to argue for feeding, even just a small amount of food. Sustain talk can be difficult to address, so I decided to offer some compromise and then affirm and reflect. With empathy, I said, “Well that is something that we can discuss with the nurse. I would just like to affirm what the food represents in your relationship. This is the way you’ve shown your love for your whole marriage, so that’s hard to stop that now. I know you don’t want to hasten his death by not feeding, but the scientific knowledge we have indicates that feeding could be more harmful.”

Betty immediately interjected with more sustain talk. “But he may be hungry,” she protested.

“I think that’s a great point,” I replied. “Unfortunately, we don’t know for sure if he is hungry or not.”

Betty interrupted and asked, “Do you think it’s better to not feed him because it’s more dangerous?”

I realized that Betty was looking to me as an expert, and as the hospice social worker, I was more of an expert on the issue. This is another temptation to resort to the righting reflex and simply use my authority to tell her she couldn’t feed him. But I reminded myself that this was Betty’s life and I did not know what was best for her. Any decision I made for her, she could still reject. She had to come to it herself. Furthermore, I needed to support her self-determination and autonomy. “Well, I think it’s better that you do what you feel most comfortable with,” I told her.

Betty appeared to appreciate this point as she sat back in her chair and relaxed her shoulders. My statement affirmed her autonomy and validated that I supported her self-determination. I realized I may not have acknowledged before that the choice had to be hers.

Although Betty had relaxed, she was somewhat hesitant. “I just don’t know,” she said. “This is so hard.”

I knew then that I needed to help Betty navigate the pros and cons of this decision. For this, I used an MI technique referred to as a decisional balance. Betty already had the information about the advantages and disadvantages of feeding and not feeding, but I needed to help her sort through them.

I asked Betty, “Well, what are some of the dangers of continuing to feed Frank?”

Betty reflected for a moment. “Well, he could choke. And you said the food could get stuck and he could aspirate.”

“Yes,” I replied, adding, “The body also cannot digest the food well, so it could store in his body and cause an infection. And what are some of the good things about continuing to feed him?”

Betty looked puzzled, but said, “Well, he wouldn’t be hungry.”

I gently replied, “Yes. If he is hungry, which we don’t know for sure and likely never will, the food could satisfy his hunger. But if the food doesn’t break down correctly or pass through his stool, then it could be more painful for him.”

Using the term “pain” seemed to resonate with Betty. Her eyes widened and she sat up in her chair. “Oh! I hadn’t thought of that. It could cause him pain?”

“Yes, think of it like this: if you eat more food than your body can handle, you get a stomachache. Now imagine not being able to get that built-up food out through your stool. That’s likely what it feels like.”

Betty smacked her arms down on the armrest and said, “Well, I definitely don’t want him to be in pain. Do you think that his pain and agitation last night was because I gave him some mashed potatoes?”

Betty seemed ashamed by this prospect. She moved in her chair and did not make eye contact with me.

Sensing her uneasiness, I softly said, “You know, we will probably never know. I’m glad that you knew to call for help when he was having new symptoms. That was very intuitive and shows that you knew what to do in a crisis.” I did not want Betty to feel guilty, because a number of factors could have played a role in her husband’s symptoms.

I wanted to return to the decisional balance to speed up our arrival at Betty’s decision about feeding her husband. “What are some of the bad things that could happen if you stop feeding him?” I asked.

“Well he could be hungry and that would make him more uncomfortable. But after talking to you, I'm not sure if he would be hungry because maybe he’s just too sick to be hungry,” Betty said sadly.

“So you’re thinking maybe he’s hungry, but we don’t know for sure. You also see that he could be far enough along in the disease process that his body isn’t feeling hungry anymore.” She nodded. To continue with the decisional balance, I asked, “And what would be the benefits of not feeding him?”

“Well you said that feeding could cause infection, so if I don’t feed him hopefully he won’t get sicker. Maybe he would live longer?”

A Breakthrough

I was so relieved to hear change talk: an acknowledgment of the possibility that Betty might stop feeding her husband. I felt that we were finally getting somewhere with her ambivalence. “He could live longer, and maybe even be more comfortable,” I told Betty.

“Yes, I want him to be comfortable,” Betty nodded.

“I want you to know that we really do understand how confusing it is to not feed your loved one at the end-of-life,” I affirmed. “It seems so unnatural because feeding is typically associated with us feeling better. And also with your relationship, feeding is not only part of your role as his caregiver for the past sixty-four years, but also the way you show him how much you love him.”

I wanted to ensure I normalized Betty’s ambivalence regarding feeding at end-of-life, as this is something that hospice clinicians discuss with families every day. Like many therapeutic interventions, normalizing is useful in MI because it makes clients feel comforted that they are not alone. This is especially critical in hospice because family members often feel isolated as their loved ones transition through the dying process. Affirming and normalizing Betty’s confusion regarding feeding, while also providing a complex reflection of Betty’s role as caregiver and how she expressed her love, helped us transition from the issue of feeding to ideas for how Betty could continue to express affection towards her husband in his final days.

“If we can brainstorm together other ways you could express your love,” I continued, “then maybe we can implement those into your caregiver role. Maybe things that are less risky, like reading to him, holding his hand, playing music for him. How does that sound?”

“That sounds nice. He loves reading.” A note of relief emerged in Betty’s voice. “We used to go to the library together and get books. Sometimes he’d read to me at night.”

“Wow,” I replied, “that is really special. So now you could maybe do that for him.”

She paused briefly. “Yes, I think he would like that. But can he hear me?”

Again, I wanted to avoid jumping into an expert role here, especially with what must have been an emotionally loaded question for Betty. “Well, what do you think?”

“I’m not sure,” she said. “He doesn’t respond like he can.”

“Would it be okay if I gave you some information about senses that some other families like to know?” I asked.

“Of course,” Betty said, “You’ve been so helpful, I want to know.”

“Well, we always ascribe to the belief that if there is breath, then there is hearing. Some studies have shown that hearing is the last sense to go before someone dies, so I always tell families to behave like their loved ones can hear them.”

“Yes, you’re right. I think he can hear me,” she said hopefully.

Peaceful Passing

Betty’s husband lived just two more days after this visit. I learned from the nurse that Betty’s husband declined even more the day after our visitand was actively dying, so I followed up with Betty and her children with telephone calls to assess the status of feeding and how they were coping. Betty and her children all confirmed that Betty had not tried to feed her husband again after our visit.

I learned from my bereavement telephone call that Betty spent the last two days she had with her husband reading his favorite books to him, writing him a long letter that reflected their life together and the impact it had on Betty, playing their favorite music on an old record player, and holding his hand and providing a supportive presence.

My visit with Betty not only provided her with important education about her husband’s dying, but also helped her process some of that anxiety so she could help Frank’s dying process be more dignified and peaceful. Like so many of the families I see, Betty needed someone to validate what she was feeling and also hear, understand, and affirm what feeding represented to her relationship with her husband.

Motivational interviewing skills, such as reflections and the decisional balance that I used with Betty, have been effective in my clinical practice with hospice patients and families who experience ambivalence with administering morphine for pain, hiring caregivers, or asking family members for help to protect the primary caregiver from burnout, and processing denial related to rapid decline.

Often families I work with are extremely concerned with doing everything “right,” so affirming that they are doing an excellent job caring for their loved one is very important for them because the feel empowered and validated. Although they may not be ambivalent about providing care, they are still at risk for becoming so overwhelmed that effective coping and a healthy life balance are damaged. Emphasizing individual strengths through genuine affirmations empowers the caregiver and results in better care and support for the patient. The patient having a peaceful death with dignity is not only valuable for the patient, but also for caregivers and family members as it decreases their risk for complicated bereavement.

The spirit of MI is rooted in the notion that the practitioner and client have a collaborative relationship. Once that relationship is established, the practitioner is responsible for evoking the client’s motivations, perspectives, and autonomy. Starting the visit with exploring and reflecting Betty’s motivations, understandings, and feelings regarding feeding allowed us to make progress on this issue. If I had come into her home telling her why she should not feed her dying husband, she likely would not have listened. Furthermore, she would not have had the opportunity to process their life and the emotional impact of her husband’s death.

MI techniques emphasize and foster a collaborative therapeutic relationship, which is critical in hospice work, and more generally in working with individuals and families coping with terminal illness. We clinicians are not the experts in our patients and families’ lives or their dying process. Using MI techniques not only helps hospice patients and families process their ambivalence, but are also extremely valuable in conveying empathy in a way that moves towards change.

My work with Betty was the first experience I had in applying MI to my clinical work in hospice. I was initially unsure how the MI skills, specifically reflections and affirmations, would help Betty resolve her ambivalence, but this experience showed me their value. I believe that my ability to avoid the righting reflex and simply repeat back to Betty her confusion and fear helped her feel heard and validated. The reflections also allowed her to process her thoughts that supported the ambivalence. These skills helped us establish a collaborative relationship as I was sure to never make her feel I was the “expert.” Although Betty saw me as more knowledgeable of the issue of feeding, I was not more knowledgeable in what was best for her. These skills allowed me to use the decisional balance, which ultimately led to her resolving her ambivalence and not feeding her husband again.

I feel tremendously honored to have the opportunity to work with hospice patients and families. Being present with patients in their dying process, and supporting their families as they navigate the demands of caregiving and effects of anticipatory grief, is an incredible privilege. I believe strongly that everyone deserves a peaceful death with dignity and am passionate about being part of providing that experience to all of my patients and families.

Maria Gonzalez-Blue on Person-Centered Expressive Arts Therapy

Posted on April 2, 2012February 11, 2026 by rezendevknowfully.com

Formula for Compassion

Victor Yalom: Maria, as I understand it you’re a person-centered expressive arts therapist. A good place to begin would be to ask you, what is person-centered expressive arts therapy?

Maria Gonzalez-Blue: I'll start with what the person-centered approach is, because that's the foundation. Expressive arts then becomes a tool that's been integrated into the person-centered approach, which was, of course, defined by Carl Rogers. The person-centered approach is based on the humanistic principle that, within every organism, there is an innate movement that will always move that organism towards it greatest potential, if it's given a nurturing environment where that potential can grow. The nurturing environment was defined by Carl Rogers as one that includes the elements of empathy, congruence, and unconditional positive regard.

VY: Carl Rogers is certainly well known by our readers and he's had an enduring influence in our field and in many fields to this day. We’ve just been doing some work with Sue Johnson in emotionally focused therapy, and she gives a lot of credit to Carl Rogers. We’ve also just been filming some videos on motivational interviewing, which also has strong Rogerian roots. What, for you, are the essential components of Rogers’s person-centered approach that you hold near and dear to your heart as you teach and as you work with clients?

MG: I see his emphasis on empathy and unconditional positive regard as a formula for compassion. It requires therapists to consider those things any time they sit before clients, students, or other individuals. If I enter a session knowing that I want to bring these elements in, it forces me to bring them home to myself, as well. I have found that it becomes a way of life and makes you a better person, because you're always conscious of when you're not being empathic or when you're being judgmental.

In my work, what I've seen is that when you listen to someone truly carefully, instead of listening to your own ideas and expectations—when you set all judgments aside, incredible things happen. People contact information that's long been repressed. It seems a simple thing, but I find it has a profound effect on an individual to be listened to with such caring.

The Intention of Tolerance

VY: Coinciding with the publication of this interview, we’re releasing on video an interview that Carl Rogers did in the ’80s. When discussing these concepts, he clarified his conception of unconditional positive regard. He said something along the lines of, “It’s not that we can always achieve unconditional positive regard, but it’s fortunate when we can have that with our clients.”

MG: Right. And that's what I tell my students all the time: what's important is to hold that intention. Certainly we're human beings—we're judgmental. If we can simply go into an environment with that intention, that is far reaching.

VY: I think that’s an important clarification, because otherwise, people can hear that and think it’s Pollyannaish. It’s an impossible ideal to attain. As you say, we’re human. We have our judgments. We have different feelings for our clients and for different people in our lives.

MG: We have to start with tolerance. I think this is why I am so dedicated to this process, because I feel we need this so much in the world. You can at least start with tolerance.

I don't think it's necessary to accept or condone everything and everyone you meet in a session. But you can keep in mind that somewhere in that organism, there is a desire towards growth.

I don't think it's necessary to accept or condone everything and everyone you meet in a session. But if you can keep in mind that somewhere in that organism, there is a desire towards growth, then that's the part that we as person-centered therapists hold: that seed in there that wants to move towards wholeness. Accepting that that is there requires trust and faith on the part of the therapist. And if the therapist can hold trust and faith, then that can affect how clients feel about themselves. If you as a therapist aren't judging them, then maybe their own self-judgments can start falling away.

Not Just Parroting Back: Reflecting as Witnessing

VY: Another one of the core techniques of this person-centered approach that I think has had a vast influence but also been misunderstood is this idea of reflection—repeating back what the client says. Some people have made fun of this as parroting or being too mechanical. What are your thoughts on that?

MG: That mirroring back of language, for people who haven’t really experienced it or been part of it, is often seen as mocking the individual. But that’s really not the case. Reflecting back the language that a client is using can also be useful, but we don’t always use the same exact words. Often, as clients are rattling off issues, problems, and feelings, they’ll say something that they’ve never said before; in their sharing, they’re coming to insights, they’re making connections without knowing they’re making connections. If you, as a therapist, can reflect back what you’re hearing, then those connections that are being made come to consciousness. Clients are speaking from a kind of flow of consciousness, and

I like to see myself as a mirror that’s reflecting back the wholeness that I see in them.

I like to see myself as a mirror that’s reflecting back the wholeness that I see in them. So that reflection is really important.

What’s also important is that you want to understand. Part of being empathic in Carl Rogers’s process is to see clients’ experience from their own worldviews. If you can really hold that idea that you want to understand, it’s also a way of saying, “Is this what I’m hearing you say?” And that gives them a chance to say, “No, that’s not it.” But, if they realize that that’s not it, then that gives them a frame of reference of what might it be. It’s a stepping stone.

VY: Right; as clients talk, they'll say things they didn't even know existed inside them. And of course, that's always the goal in any kind of therapy—that people will discover new things about themselves. If they're repeating things that they already know, then not much new is happening.

MG: Exactly. It’s like the therapist is walking through the woods side by side with the client, discovering things together. There’s something about that witnessing that can ground those new discoveries in a way that people can’t really do on their own.

VY: That’s a nice image. I’ve seen videos of Carl work and, of course, many other master therapists from different orientations. And what comes through is not his technique or the words he utters. Instead, you get a such strong sense of him really being with clients, listening deeply, committed to hearing and understanding them. I think it’s the intention. It’s the spirit of it, rather than the words that come out, that really is profound.

MG: And for many people, this has never happened. Even your best friends, and particularly family members, have all kinds of biases. They know you as this certain person. Sometimes your best friends want to help you, so they give you advice that may have worked for them, but may not work for you. But when you want to hear your clients, when you want to really see their worldviews and understand them, something shifts.

The Blank Page: Exploring the Unknown with Art

VY: Tell me about the expressive art component and how that is integrated into the person-centered approach.

MG: We just talked about a client discovering buried material, stepping into unknown material that strikes a surface, which is a good segue. Often, clients who enter therapy are approaching unknown territory. Either they’ve left a job or a relationship, or their life doesn’t feel right anymore, so they know what’s not working, but they don’t know what’s ahead.

The blank page, whether it’s in visual art or movement, is a great way to enter this unknown material. Art is really the language of the unconscious; it allows symbols to come forth. People make discoveries of potential and understanding, which become new resources to enter this unknown material. I believe that there’s a time and place for everything, so I’m not critical of any therapies. But talk therapy has its limits; art does not. It can be limitless. It can also be contained.

VY: I should add at this point that person-centered expressive arts therapy was developed by Natalie Rogers, Carl's daughter, who's a psychologist and psychotherapist in her own right, as well as an artist. And I know you've worked and trained with her professionally over many decades.

MG: Yes, we've worked substantially together, we've taught together, and we've played together. And what Natalie really brought in to weave those two things together was what she came to call the "Creative Connection." It's actually an intermodal process where we work with different modalities in sequence. A person might be exploring an issue through a visual arts piece. We don't diagnose or interpret art; instead, we ask the artist to explain what came through as a feeling, what is in the art that he or she wants to discuss.

The art doesn't have to be analyzed or intepreted. It's an image that has its own language.

The art doesn't have to be analyzed or intepreted. It's an image that has its own language. So the work is processed through listening, really respecting what the artist has to say about it. If the client wants reflections that a therapist might have, I might add something that I sense in the art without trying to analyze it—maybe noting the energy or the color, the person's body language in the making of it. I like to observe body language; sometimes you can tell energy is moving through.

VY: When you say artist, of course, you’re just referring to a client who’s engaged in the expressive arts process.

MG: The person who made the art.

VY: Yes. I don’t want to our readers to think that only artists can be involved in expressive art therapy.

MG:

We are all artists of our own lives.

We are all artists of our own lives. Expressive arts therapy is not looking for an end product, necessarily. It's really about the process and what comes through in doing the art.

Introducing Expressive Arts into Sessions

VY: Can you say how you use art? As you said, people are often going through changes. They're talking about concerns in their lives, some situational issue or an emotional reaction to that, feeling depressed or anxious. How do you go about introducing the expressive arts into a session?

MG: Pretty early on, I observe the client. I bring my intuition into my sessions. I watch body language. Let's say I have a client who is really kinesthetic, moving a lot while she's talking, making certain gestures—for example, she's talking about an issue, and she keeps putting her hand on her heart or keeps holding a part of her body. I might ask her if she'd be open to movement work. And whenever I introduce anything, I do it with a lot of asking permission, asking how it feels, so she doesn't feel like they're being directed. But she's given the opportunity, the invitation, to explore something.

VY: One of the other names of the Rogerian approach is non-directive therapy.

MG: Exactly. And what's important about that is that it makes clients ultimately responsible for their own processes. So I might ask if she would feel comfortable just holding that posture for a bit. Often what happens is the client may hold that gesture, perhaps holding her heart. And then I see more come into it—maybe her shoulders lift up, her facial expression might change. So I say, "If it feels right, why don't you go with that movement and see if there's more there?" And that's a subtle invitation to enter a movement process.

VY: And how might that evolve? A client might get up and move around or dance?

MG: She might get up and move around. She might move where she’s sitting. And if a client feels shy, sometimes I say, “Would you feel more comfortable if I move with you?” Because the body has its own wisdom. What’s happening here is that we’re tapping the body’s wisdom to help inform the person, maybe of something that’s repressed, or something that really wants to come alive. Then I just might check in and say, “What’s going on? What do you want to share about that movement?” At that point, people can easily start describing what they’re feeling, what they’re understanding. Sometimes they have their whole stories come forth. It’s like opening a door into the body.

VY: So, in this case, movement might in turn elicit some emotional reaction or some image or ideas that then they’ll go back and process verbally?

MG: That gives them better understanding. They might process it verbally. If there's time, they could do some freewriting. And I might suggest making some quick "I am" statements to see what comes. It also could go into some art—whatever the client is feeling. I'll usually have chalk pastels and oil pastels. I'll ask, "Would you like to take a color and see if you can draw that shape, or just see what comes through?"

There's so much happening when you tap this deeper language. Using pastels has been a really successful way to draw shapes, draw feelings. Sometimes I start my workshops by having people draw their breath going in and out, and it's such a abstract concept that no one has to feel that there's a right or wrong way to do it.

VY: I’ve seen Natalie say, “Would you like to work with color?” And my sense is that that’s a way of de-emphasizing that this has to be some artistic creation. It’s more just an experience of taking some colors and playing with them.

MG: Yes, it’s very much a meditation. In fact, I use the word “scribble” a lot. I tell people, “When we’re done, you can just throw this away. It doesn’t have to be put up in an art gallery somewhere.” It’s really about what’s happening when clients go into the stillness to just be with themselves in the process, but with me as a witness.

VY: Just so our readers can get a better idea, can you give an example of how this is used in individual therapy?

MG: I have a new client, and this client is an artist. It's funny; I work with all people that are creative, and people come from all different walks of life. But I typically don't work with artists. We talked for a while; she's had some major changes in her life, and she was feeling a block from her artwork.

I talk with clients, too. It's not like it's all expressive arts. In fact, in some cases I may not bring the arts into it if it doesn't feel relevant at the moment, or if it doesn't feel in the flow. But in this case, I asked her if she would like to do some artwork before she went further to her issues. I had her work with pastels. I had her, first of all, just look at the colors and see if there was a color that she was attracted to start with. I let her know, "This does not have to be an art piece. This is a process." I always try to make that clear.

And what unfolded was that she drew aspects of her life in very basic, rudimentary forms. And there were some surprises already, in what she saw there. This was after she came with the issue of block in her artwork. Then we turned to process a little bit more, her sharing her story, which I won't go into. I listened to her carefully. As she talked, she was able to make some discoveries of elements of her life connecting to ongoing issues that she was aware of.

I had her do a second piece towards the end, and the interesting thing was that she was drawn to all the same colors, but this time in her drawing, everything seemed connected, whereas before they had seemed to be these small, disconnected pieces on the paper. Now there seemed to be flow—all the same colors, but everything seemed integrated. You could see movement. A change had happened, and it's not something that's easy to articulate. But using the arts, she could see it. And she could feel it in her body.

It's not something you can read in a book. You can explain details, but until you feel the changes firsthand, you don't get it fully.

Like you say, it's hard to articulate a lot of this because so much is happening at the cellular level, the emotional level. I think all of us who facilitate the person-centered approach have felt like it's not something you can read in a book. You can explain details, but until you actually live it, experience it, and feel the changes firsthand, you don't get it fully.

VY: Coinciding with this interview, we’re publishing a video (LINK) of Natalie working with a client for two sessions. Having a chance to watch that, I certainly got a clear sense of the power of this approach, and how shifts can happen in a short amount of time.

MG: And what I have noticed is that the shifts tend to stick. I'm still in touch with students I had long ago from our training program, or past clients. Person-centered therapy can help to build that self-trust and the trust in the natural movement towards growth. I really try to encourage my clients to know this, and I think that it helps life changes to be healthy ones.

Using Art in Groups

VY: Natalie's first book on this topic was The Creative Connection, and I know she just recently published a follow-up to that, The Creative Connection For Groups. I know you also work with groups. Do any examples of work you've done recently pop to mind?

MG: There's a group process that really stays in my mind, where I saw the profound effect of person-centered and expressive arts therapy. I was doing a seven-day training program. What we like to do is invite feedback every day. It always feels like a bit of a risk to open yourself to feedback, but I find that it's really important because people need to feel that they're safe and that whatever they're feeling or going through is okay and a process.

So I was doing a training, and during a morning feedback session on our second or third day, something arose between two women. It was something about a transportation conflict; one of them was very upset that the other hadn't waited for her at the airport. I said, "Let's go ahead and take some time," and asked people to say how they felt, without blaming, if they could. That's not always possible.

But the people in the training were versed enough in the person-centered approach that they were open to hearing whatever needed to be said. Both these people spoke, and then a couple other people started speaking. The conversation got quite heated. I let it go for a little bit, and then I intervened and said, "I'd like to make a group agreement, because many people are not involved in this conversation. It's important for you to express how you're feeling. But I know there are people who also want to do some work. So can we put a time limit on it?"

So we compromised, and the conversation continued about transportation and what one person said and the other person said. At some point I said, "Okay. The time is up. Do you want to keep going, or shall we do some art?" And, of course, all the other people said, "Let's just do art." So I laid out a huge mural sheet and put on some music that was kind of driven, because I could tell there was a lot of heat in the conversation. We got out paint, and people started just drawing on this mural.

And as a witness of this process, I could see the energy shifting. At first, the drawing people were doing was kind of intense and stark, big. But by the end, people were starting to write poems, affirmations about themselves and their desires. Some spontaneous singing started happening. By the end of that process, I could feel that everything had shifted.

Ultimately, what I know is that in a process like that, those surface feelings that come up are not about the people themselves, but about inner issues that people are grappling with. And to give it space to be there is really, really important.

Collectively, we like to hide that negativity, hide our anger, come to the table with a smile. But something really beautiful happens in the community when people are allowed to be "negative" in a group and have that held—when you see that that's okay and no one's judging you for having those feelings.

The next morning when we had our check-in, it was totally different. People were sharing personal feelings about their woundings and discoveries, but it had nothing to do with the group anymore. So it's really very amazing to see.

VY: Are you suggesting that people may have an easier time expressing some negative feelings through expressive arts than they might be able to put into words?

MG: Yes, because a lot of times the words can be hurtful, or the words aren't even there. It's just this strong energy moving through the body. If you can put that into some artwork, it becomes a creative fire. You can move that strong energy through and see what's underneath it. And that's exactly what happened with that group process.

Building Bridges: Art in International Group Work

VY: You've trained a lot internationally and you've cofounded an expressive center. Is it in Argentina?

MG: That’s right, in Buenos Aires. We have person-centered programs now in many countries.

VY: Any thoughts or comments about doing this work internationally?

MG: The beauty of the person-centered approach is that it lends itself to meet any group, any culture, exactly where it is. You design any program you do towards who you're working with. I don't go in with a structured program. I have a sense of where we might go, but it's always fluid. So with every culture, first I get to know the culture. I hear from them. I hear what they might need.

In Argentina, I knew a little bit about the background of a violent dictatorship in the '70s. So I went into that culture with a lot of humility. What I found was that the culture needed a very tight structure in the beginning. Everything needed to be on time. I needed to be perhaps more directive than I usually am. That just meant that if we were working with a certain modality, I would try to keep everybody with a certain modality, whereas working in an environment where there's already a lot of trust, I might just say, "Whatever modality you want to work with, you can."

But, what I found in Argentina was I needed to hold a tighter structure at first to develop trust. It's a culture that hasn't been able to trust their government in the past, so self-trust then comes into question. The beauty was that their hearts were so tender and beautiful that by the end of the ten-day program, everyone wanted to come back. Everyone wanted to go deeper into the work.

The person-centered approach really has a potential to bring great things into our planet, to bridge cultures.

The biggest thing that I want to underline in working with other cultures is that I think the person-centered approach really has a potential to bring great things into our planet, to bridge cultures. I think it's really important as a way of being with cultures that's accepting, that can bridge us into healthier places.

VY: It seems the arts are an international language. Have you had a chance much to work with groups of people from different cultures in the same group?

MG: Yes. In fact, CIIS (California Institute of Integral Studies) is very multicultural. The art becomes the universal language then. A closeness happens with these groups. What happens in group process is it’s almost like they start dreaming together when the art images start to appear. After the group has been together for a while, these same symbols end up appearing within the group as if they’ve just had the same dream. It’s a wonderful bridge.

First Impressions in Psychotherapy

Posted on March 11, 2012February 11, 2026 by Psychotherapy.net Team

A woman wrote to me, having heard me on a radio programme. She had picked up my concern that not enough attention was being paid to the quality of the therapeutic relationship (as opposed to techniques) and wondered how her 25 year-old son, who was seeking a psychotherapist, could assess that in advance of therapy when neither of them knew any therapists where they lived. The obvious answer is that he should wait until he and the therapist meet. Therapy is after all a personal relationship and only by knowing the person could there be a real alliance. If on meeting the therapist for the first time, he felt uneasy or badgered or misunderstood or puzzled or demotivated, then perhaps the therapist was not the right person and he should find someone else. But is that right?

First impressions are important. Think of meeting someone for the first time and how even after the end of a brief exchange, you have already formed an opinion of them. I met a neighbour at a party my wife and I gave, someone I was prepared to like having already met his charming wife. To my surprise, I disliked him. What was it about him that provoked this strong reaction? Thinking back, I realised it was that he had shown not the slightest interest in me and my attempts to engage him in conversation had been met with distracted inattention. I even resented the fact that, when I moved past him to get someone a glass of wine, he made no effort move aside! (This says as much about me as him, I realise). A prospective client could do something like this, evaluating the therapist by how he or she responded and how the client felt in the session.

But therapy is not the same as a conversation. Most therapists are good at putting clients at ease, asking questions sensitively, listening attentively and making the client feel safe and understood. For most clients the experience of the initial session is likely to be positive, allaying anxiety, reinforcing the hopeful expectation that at last help is at hand. Unless the therapist is distracted or disturbed, the first session will generally pass well. That does not mean the therapy will always be bathed in this arm glow of positivity and, if it were, we might wonder whether the therapy was really that helpful. As Patrick Casement points out in his autobiographical memoir, Learning from Life, good therapists must learn they should not always be nice to their clients.

In the first session unconscious processes in both therapist and client will be at play. I recall reading about a client who knew from the therapist’s name alone that he would be the right one for her. Once I heard a client’s hesitant and garbled message on my answering machine and that made me reverse my just made policy of not taking on any new clients. And on another occasion, opening the door to a new client I took fervently against her and, to my shame, manoeuvred the session so that I could refuse her help. For all these factors, conscious and unconscious, the first session may not be the best place to judge the therapeutic relationship, although of course a judgment will inevitably be made. The truth is that the success of the relationship can be judged only in the experience of it.

Perhaps I should be a bit more psychological in my response to this woman’s question. Why was she contacting me, not her son? Was she just an over-protective mum, simply anxious that her son should find the ‘right’ therapist? Or was she anxious that he would find such a therapist who would replace her? Was she seeking help for herself? I don’t know and, no longer being in practice, means I will never know. My first impressions therapeutically occur now only in the virtual world and that is altogether different.

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