Category: Expert

Listening as Meditation

Posted on by Psychotherapy.net Team

In 1975, Herbert Benson of Harvard University wrote that to achieve a “relaxation response” you only need four ingredients. These included (a) a quiet place, (b) a comfortable position, (c) a mental device, and (d) a passive attitude. Benson’s relaxation response was, of course, roughly equivalent to the meditative mental state. His work presaged the mindfulness movement in psychotherapy. He identified a psychological place of exploration, discovery, and acceptance. His research linked the relaxation response to a variety of physiological and psychological benefits.

Carl Rogers and his daughter Natalie have often lamented that modern American therapists simply don’t understand person-centered counseling. As I watch students and professional therapists all-too-often engaging in premature problem-solving with clients, it’s easy to agree with Carl and Natalie. No one values listening much; it’s too slow and plodding for our caffeinated culture. Therapists wish to be helpful. Clients wish for solutions. And together they conspire to avoid whatever might lurk beneath the surface. At my present institution we even have a one-session group counseling experience called, “Feel Better Fast.” Perhaps what’s most amazing is that these explicit efforts to embrace and engage in the quick-fix are sometimes effective. This may be nothing more than a testimonial to the power of expectation and placebo.

But it’s equally likely that the help that happens comes primarily from two valid sources: First, clients may perceive their therapists as genuine and sincere. This is perhaps a small measure of Rogers’s person-centered congruence communicated through a fog of directive or solution-focused problem-solving. Second, some clients show up for therapy ready to learn. This is an example of Prochaska’s readiness to change—a pleasant situation wherein whatever stray skill that happens to graze the client’s psyche may be adopted, adapted, and applied, with some success, to the client’s particular life or problem. Obviously there are some good skills out there (including mindfulness meditation) and, as Otto Fenichel might have said—referring to psychoanalytic interpretations—timing is nearly everything.

Instead of indiscriminately engaging in procedures or firing off solutions, I wish that students and young professionals could step back and experience listening as meditation. I wish they could follow Benson’s advice and get comfortable, breathe deeply, and let their clients’ words into a quiet space. And while continuing to breathe, I wish for them to explore, discover, and accept what their clients are thinking, feeling, and experiencing.

Sometimes, when listening to therapy recordings with students I ask questions like:

  • Do you hear a value rising up in your client’s voice? Just listen and accept it and reflect it back.
  • Do you sense that your client is expressing perhaps a taste of bitterness mixed with unhappiness? If so, help your client hear and understand her or his own emotional state.
  • I wonder if you could tune into the call of the psychodynamic here; let the repeating interpersonal relationship patterns become clear; and then, collaboratively explore and discover with the client the nature, cost, and alternatives to these patterns, keeping your mutual and evidence-based goals in mind.
  • Do you notice in your client’s words the scent of the somatic or the spiritual? That’s okay, just notice it and then try to be the mirror that enables your client to see it right along with you.
Lately, the main message I’ve been trying to give my students, my supervisees, and myself is to integrate Benson’s and Rogers’s perspectives and use listening as meditation. The point is to let what the client says become the central focal point (Benson’s mental device). This is then followed with mindful acceptance and empathy, leading to a collaborative and interactive search for meaning or solutions or insight or behavioral prescriptions or cognitive reframing. And it ends with my conclusion that one of the coolest things about listening as meditation is that you can do it using virtually any theoretical perspective because excellence in the art of listening is the foundation that virtually all excellent therapists share.

John Sommers-Flanagan on Clinical Interviewing and the Highly Unmotivated Client

Posted on by rezendevknowfully.com

When In Doubt, Act Like Carl Rogers

Victor Yalom: You and your wife, Rita Sommers-Flanagan, are well known in the field for your work in Clinical Interviewing, and we are delighted to be releasing your video on this topic concurrently with this interview, but before we get into that, I know you’ve also done work with mandated or otherwise unlikely and unwilling clients. Much that’s written about therapy implicitly assumes that the client is there willingly, but in many settings, clients are overtly coerced into coming by courts or institutions, or they’re strongly nudged into treatment by their parents or spouses. How do you work with these clients?
John Sommers-Flanagan, PhD: A lot of my thinking in this area sprang from the work I did in private practice, primarily with challenging teenagers. As you can imagine, many of them did not want to be in the room with me, so the challenge was, “How do I engage this person?”

I have a vivid memory of a young man who spent 30 minutes just saying, “fuck you” to me. I remember trying to go through every strategy I could think of. But probably the best of all was just to try to be like Carl Rogers and listen in an accepting way to that particular message over and over again.
VY: Did you literally reflect it back to him like Carl did, verbatim?
JSF: Well, Carl had a case known as, “The Silent Young Man,” where he’s treating this young man who doesn’t want to speak at all, and I think I was trying to channel him in that situation. So I started off by saying things like, “Well, it sounds like all of a sudden you’re pretty angry with me.” And all I got was, “Fuck You.” Then I was saying things like, “It’s clear that there was something I did or said that offended you and I’m not sure what it was.” Then I did a little self-disclosure. After about 15 or 20 minutes, he was still just saying, “fuck you,” but he started singing it to me as 15-year olds might be inclined to do. That went on for 10 minutes and I’m doing my Carl Rogers impersonation, “Well, you sound like you’re not happy, but even though you’re still swearing at me, you’re not angry any more. Now you’re happy and singing it to me.”
What happened next was really interesting. Keep in mind this was not a first session, it was a sixth, maybe seventh session. When he came in the next week, he sat down in the same chair and looked at me. I was anticipating more anger and more resistance, but the first words that he said were, “I’m just wondering, how would you feel if you were to adopt me?” Which was kind of a shocking change, and actually much more difficult than, “fuck you.”
VY: What did you say?
JSF: Well, he said it in this kind of off-handed way, and I just decided at that moment in time that I should try to be genuine and I responded with some disclosure about feeling a little nervous because this was a young man who had a pretty significant history of violence. I said, “I think I would feel pretty nervous about some of the ways that you’ve been with people.” And that launched us into a different discussion.
For me, it sort of captured how important it is to be, as Marsha Linehan might say, “radically accepting of what the client brings into the room.” Or as Rogers would say, “You just kind of work with what you’re getting.” It seemed to help us go deeper and it facilitated exploration and more engagement.

“You sound like a stupid shrink and I punched my last therapist”

VY: So one thing I get from this nice story is the underlying message of really hanging in there with a client, even in an extreme case where they’re coming in and swearing at you perhaps for the whole session or half a session. Really being there and meeting them head on, and being as genuine as you can.
JSF: Absolutely. A more common example is one that I get all the time with some of the difficult young adults I work with now. A 20-year old very recently came into therapy and I said something like, “Welcome to therapy, how can I help you?” And he says, “You sound like a stupid shrink and I punched my last therapist.”
This again captures a lot of the pushing and testing that happens with reluctant clients. I said, “Well, thank you very much for telling me that. I would never want to say anything that would lead you to punch me, so, how about if we decide that if I say anything that makes you want to punch me, you just tell me and I’ll not to say it anymore?”And the kid sat back and said, “Wow. Okay. That’s alright with me.”

VY: How do you conceptualize uncooperative or unwilling clients?
JSF: Well, there are few different dimensions. The first is how they’re referred. They’re often referred by a probation officer or principal, or the parents bring in someone or someone is abusing substances and has been given an ultimatum, or a spouse insists on some kind of counseling and so they come sort of unwillingly into the room.
Then there is the way that their resistance manifests in the room. Sometimes it manifests in silence. “I’m not going to talk to you and you can’t make me.” My standard response to that is what I think people have referred to as a concession where I say, “You are absolutely right. I cannot make you talk about anything in here. I especially can’t make you talk about anything you don’t want to talk about.” With teenagers, I will say that and then I’ll pause and I’ll say, “Well what do you want to talk about?” It’s like they need to posture by saying that they won’t talk, and when I concede that they’re right, that they do have control over themselves, then they tend to respond.
Other times, as I’ve just talked about, resistance is much more aggressive. I remember an older man who said, “We might get in a fight in this meeting.” That’s a much more aggressive kind of resisting the initial contact.
And, lastly, there are some people who resist through externalizing, as in, “the problem is with my school,” or “It’s with my spouse,” “it’s with work,” “it’s with everyone but me.” The challenge then is to listen empathically without getting too frustrated, because if I get frustrated and accuse the person of externalizing, oftentimes it just makes them more defensive. Those are three different categories I can think of off the top of my head: the very silent client, the very aggressive, and the very externalizing client who has a lot of trouble taking any initial responsibility for his or her problems.
VY: So aside from acceptance, empathy, and trying to really be there authentically, what are some other key principals for the therapists working with these kinds of clients?
JSF: I don’t know if you remember Mary Cover Jones, who did some of the early work with John Watson on helping young children desensitize their fears, but she said, “We have two means through which we can help decondition people. One is counter conditioning, where you have some kind of positive stimulus that you pair with the anxiety-provoking stimulus. And the other one is through participant modeling.” She wrote about that in 1924, and it was pretty amazing stuff at the time.
So I have started to reconceptualize people who are resistant to therapy as people who are anxious about the situation. I think, “How do I produce an environment that is going to counter-condition anxiety? What’s in my environment that might help people feel more comfortable and less anxious?” It’s another principal I’m often thinking of in a clinical situation.
VY: I can’t help but note that you’re pleasantly eclectic. You’re combining the epitome of humanism, the person-centered approach of Carl Rogers, with hardcore behaviorism.
JSF: I don’t consider myself a behaviorist, but I also think that if we don’t understand behavioral principals of reinforcement and classical conditioning, we can inadvertently do all the wrong things.
Foundationally, I want to have an office, I want to have a wardrobe, I want to have a way of being with clients that is going to counter-condition any anxiety that the person might feel.
I want to have an office, I want to have a wardrobe, I want to have a way of being with clients that is going to counter-condition any anxiety that the person might feel. Mary Cover Jones used cookies with children, and when I work with teenagers, I absolutely use food. I will have some food, fruit snacks or something nutritional in the room that I can offer, and in some ways I’m thinking absolutely behaviorally at that point. And I’m also thinking relationally—it’s about having a supportive, mutually collaborative relationship. We’re working together.
VY: Can you say a little more what you mean by examples of counter-conditioning anxiety?
JSF: Well, I was just looking through Skype into your space and you have some fabulous artwork. And I think it’s important to have a room that has comforting, pleasant artwork and other kinds of symbols that will help put people at ease. And if you’re working with LGBTQ people, there should be some kind of symbolic communication that you are welcoming those people into your office.
Same thing here in Montana. We work a lot with the Native American population, and it’s really important to have some sensitivity and representation in our office of that sensitivity.
When working with younger clients, the same thing applies. I was supervising a young man who had a 16-year-old boy client who said, “I will never speak to you about anything important in my life, period.” We knew from his referral info that he had been the person to discover his father had hanged himself, so he had some terrible, complex, traumatic grief.
My supervisee said, “What am I going to do?” And I said, “Take the checkers. Take backgammon. Take some games. Take some clay. Take some things into the room. And don’t force him to talk. Just be with him. Play.”
They played for three sessions, just played backgammon. And at the end of the third session, the client looked at the counselor and said, “Well, should we keep seeing each other? Because you said I only needed to come three times.”
And the counselor said, “Yeah, I think we should keep going.”
And the client said, “Well, okay then,” and he pushed the backgammon set aside and starting talking. To me it seemed like a great example of counter-conditioning. They used playing games as the stimulus that was pleasant and non-threatening.
VY: And participant modeling?
JSF: That’s really important, although obviously you can’t really have other people in the room modeling, so the therapist is the model, and is modeling comfort in all things. Comfort when the client says, “I’m feeling suicidal.” Comfort when the client says, “I want to punch you in the nose.” The response is to appreciate those disclosures, instead of being frightened by them. Being frightened by the client’s disclosures is going to feed the anxiety, instead of counter-condition it or instead of modeling, “We can handle this. We can handle this together. It’s best if we do talk about all these things, even the disturbing things that you bring into the room.”
VY: How do you help students, beginning therapists, achieve that? And, how do you balance that portrayal of comfort with authenticity when, in fact, beginning therapists may not feel at all comfortable?
JSF: That’s a great question, and it’s one of the challenges because you want the therapist to be genuine, and yet at the same time you want them to be comfortable. And often those two things are a little bit mutually exclusive.
But I think first of all, information helps. It’s helpful to our trainees and interns and young therapists to really understand and believe that, for example, suicidal ideation is not deviant. It’s not pathology. It’s an expression of distress, and if people don’t tell you about their suicidal ideation, then they are keeping it inside, and they’re not sharing their personal private experience of distress.

I try to do a lot of education around that, whether it’s suicidal or homicidal ideation or trauma or whatever it is that clients might talk about. It’s really important for young therapists to know if they don’t talk about it, we’ll never have a chance to help them with those legitimate, real thoughts and experiences that they’re having.

And the other big piece is practice, practice, practice.

VY: How do you practice these things?
JSF: To give an example, a lot our students initially do suicide assessment interviews, and they’ll say to their role-play client, “Have you thought about hurting yourself?” I’ll interrupt and say, “Okay, now use the word ‘suicide.’” Now say, “Have you thought about killing yourself?” I’m wanting them to get comfortable with the words and to practice using those words so that they aren’t so terribly frightening.
I remember supervising a new student who was conducting an initial assessment, and about half-way through the 30-minute interview, his client says, “I used to have a terrible addiction problem, and one of the things that really has helped me with my recovery is cycling. I’m an avid cycler and it’s really helped me with my drug and alcohol problems.”
At which point, he freezes in panic and says, “So what kind of bike do you have?”
I stopped the tape and said, “Hey, what was going on?” He says, “I was scared, I didn’t want to open things up.”
I said, “Well she did. She opened it up. She shared with you that she had an addiction problem, that she was in recovery, and that she had a method that really is helpful to her. So it would be perfectly natural for you to then use your good active listening skills and ask an open question or do a paraphrase or reflection of feeling, and to stay focused on the target, which was addiction recovery coping, instead of asking what kind of bike she had.”
So it’s a combination of offering encouragement, practice, and feedback.
VY: In addition to behavioral principles and humanist principles, what other theories or principles do you draw from?
JSF: Well, in the psychodynamic realm, I’m thinking of Edward Borden’s work on the working alliance and his effort to generalize it from the psychoanalytic frame to other frames. And the emotional bond between therapist and client, which Anna Freud wrote about initially. We really try to facilitate that.
We also engage in collaborative work toward goal consensus between therapist and client, and it could be that we agree that the therapeutic task involves free association and interpretation and working through. Or it could be a therapeutic task that involves exposure and a real behavior modification approach.

Clinical Interviewing

VY: You and your wife Rita Sommers-Flanagan have written a comprehensive and widely-used textbook entitled, Clinical Interviewing, about the initial stage of therapy, where you’ve examined and broken down in great detail all the aspects that those first few sessions. Can you explain what you mean by “clinical interviewing?”
JSF: It’s a term that originally referred to the initial psychiatric interview, which has a lot of assessment in it. So it refers to that initial contact. But as we have grown, we’ve come to see it as not just an initial contact. In some ways, every contact is a clinical interview in that every contact involves this sort of two-headed goal of assessment and helping. And then the third component is the working alliance, or the therapeutic relationship.
As we know, assessments in a clinical interview produce more valid data if we have a good working or therapeutic relationship. The evidence is very clear that therapy outcomes are more positive if we have a positive emotional bond, and we’re working collaboratively on goals and tasks. So I see the therapeutic relationship as central to the assessment and the helping dimension of the clinical interview.
VY: It’s the beginning phase of therapy.
JSF: Yes.
VY: In reading your text and also in viewing the video we’re releasing conjointly with this interview, you really emphasize the importance of the therapeutic relationship or rapport-building as an integral part of that initial contact.
JSF: Right. Even if you’re doing something as straightforward as a structured diagnostic interview, or a mental status examination, you really want to engage in a therapeutic way with the patient or the client.
VY: Because you’re not going to get much information or accurate information if they don’t feel like you’re on their side?
JSF: Absolutely. It’s about establishing trust and helping people to be open. I’m very familiar with your father’s work, and in The Gift of Therapy, he writes, “In recent and initial interviews, this inquiry into the typical day allowed me to learn of activities I might not otherwise have known for months.
Even if you’re doing something as straightforward as a structured diagnostic interview, or a mental status examination, you really want to engage in a therapeutic way with the patient or the client.
A few hours a day of computer solitaire, three hours a night in Internet sex chat rooms under a different identity, massive procrastination at work, ensuing shame. A daily schedule so demanding that I was exhausted listening to it.”
And he goes on and on about these disclosures that he was able to get by asking a simple question, “Tell me about your usual day.” To me, that’s a great example of how rich the assessment data can be with a simple question, if you have a positive rapport and therapeutic relationship.
VY: So it seems like a fundamental balancing act that you’re always dealing with is how do you balance getting sufficient information—particularly if you work for an agency where forms are a part of the process—while establishing sufficient rapport. Because if they don’t come back for a second session, the treatment is surely a failure.
JSF: Right, how do we balance the information-gathering task that we might have for our agency with the relationship task? And how do we do that with culturally diverse clients?
One of the things we try to do in the Clinical Interviewing book is to go into detail—with an outline and structure—of different kinds of initial clinical interviews, including the intake and the mental status exam, suicide assessment, diagnostic interviewing, and other kinds of interviews, yet emphasizing throughout the importance of the relationship.
So if I have a checklist that my clinic is requiring me to fill out, I would say to the client, “This part of our task today. I am supposed to ask these questions and record your answers, but I also want to hear from you in your own words things that you’re experiencing. So I’ll try to balance that with you.” And I’ll actually show them the questionnaire or the checklist.
VY: So be transparent.
JSF: Be transparent. Absolutely.

Multicultural Competence and Moving Beyond Your Comfort Zone

VY: You mentioned different cultures. What are some particular considerations that come to mind about that?
JSF: Well, some of the principals that come to mind for me involve respect for the native culture here in Montana and throughout the U.S. I think respect is a core part of beginning any relationship. And I think respect involves understanding and being able to pronounce the names of various tribes, asking very gently and respectfully about tribal affiliation here in Montana. I will sometimes say that I know some people from, say, the Crow tribe who have been students in our program. Even if they don’t know the particular students, it can be helpful to hear that I have had contact with somebody who’s got the same tribal affiliation as them.
Cultural competence also means that we take the time to read and study about working with Latino or Latina clients. It also involves using what Stanley Sue referred to as “dynamic sizing” and “scientific mindedness,” where we try to figure out, “Does this cultural generality apply to the specific cultural being in my office?” That’s a difficult but very important thing to determine.
VY: Just a couple weeks ago I had the privilege of interviewing Stanley Sue’s brother, Derald Wing Sue, on multi-cultural issues. One of the things he emphasized was really getting outside of your comfort zone and getting to know these other cultures on a more than superficial level.
JSF: Another thing he really emphasizes is the question that can’t help but be in the back of the mind of many minority clients: “Is this therapist the kind of person who will oppress me in ways that other people in the dominant culture have oppressed me and my family, my tribe, or my culture?”
One of the remedies that he and others have talked about is for therapists to be more transparent, and use a little more self-disclosure. Because without doing that, there’s just no good evidence that we’re not the oppressor or the “downpressor” as some Jamaicans would say.
So diving into the culture, getting to know it on more than a surface level, and then being able to use some of the principals that Stanley and Derald Wing Sue have articulated well is essential. It makes things much more complicated and much more rewarding.

Intake Essentials

VY: There are many models of how that initial client contact occurs—from a brief telephone intake to, in certain settings like substance abuse or mental health treatment centers, having a designated intake worker who passes on the client to interns or therapists. Do you have a general recommendation or sense of what the best practices are for the initial intake?
JSF: Well, in agencies where there is a handoff from an intake worker to other therapists, it can be difficult to maintain the therapeutic connection. In that case the initial session becomes much more about clinical assessment than initiating therapy.
Constance Fischer and Stephen Finn have written about these kinds of therapeutic assessments since at least the late 1970’s, and they suggest complete transparency through the process. “Here’s how things work in this agency.
This will be my only session with you. I would like to work longer with you, but what I’m going to be thinking about during our time together is who might be the best match for you for ongoing counseling or psychotherapy.”
Without that transparency we run the risk of alienating the client—leaving them feeling like, “Oh, man, I have to go through all this again with another person next week?”
VY: It’s hard enough for people to get into treatment in the first place. As I often say to clients, “People are not usually waiting in line to get the therapy.” It often takes people years.
JSF: Right, and when we put another hurdle there it makes it even more difficult. So it’s important to explain the hurdles and let them know how best to get over the next hurdle.
VY: Is your general sense that it’s better not to have a separate person doing the intake if possible?
JSF: I think it’s better to have the same person do the intake and then continue with therapy. There are, of course, exceptions to that. If you have someone who is not well-trained in substance abuse therapy, and then it becomes clear in the first intake session that this person has an active substance abuse problem, transferring the person to a therapist or counselor who has that experience would be a better fit.
And you can just explain that to the client, although oftentimes the client will still say, “Oh, but I’d rather work with you.” But as long as you have a good rationale, you can make that transition relatively easily. So, yes, it’s best to have the same person do the intake and then continue with the therapy, except in situations where there’s a clear rationale to do otherwise.

Treatment Planning

VY: What are your thoughts about treatment planning? There’s a lot of emphasis on that in many agencies. Do you think that’s something that actually can be done with any specificity? So often someone comes in thinking they’re here to work on X, and six weeks later, you’re really working more on Y. So at times I wonder who the treatment planning process is really serving. Is it really serving the client, or is it serving some agency needs, some funding needs, or the anxiety of the therapist?
JSF: I remember an old supervisor saying to a group of us, “We’re not technicians. We can’t really lay out a protocol for exactly how to act with every client. Every client’s unique, so we need to go deeper than that. We’re professionals, and we bring both art and science into the room.”
I think it’s important to blend the two.
I’m not a big fan of cookie cutter treatment plans. But I am a fan of looking at the plan, talking with the client about what our plan is, and being somewhat explicit and collaborative in that process. I see it as a kind of dialectic—it’s a little bit cookie cutter in that it doesn’t bring in much of the individuality of the client but it does have some important information for us. From there we can dive into the unique qualities of the client and their experiences.
As an example, let’s just say you have a client who’s impulsive. We know that there are certain kinds of treatments that we might use with someone who is diagnosed with ADHD who is impulsive, where those impulsive behaviors are getting him or her in trouble. It’s good to know about CBT and other kinds of therapies that might help with impulsivity. But it’s also really important to get into the mind and, in some sense, the body of that individual client to understand what’s going on with that person.
But knowing that there are probably triggers that increase and decrease impulsivity is something you’d want to work on with a CBT treatment plan. It can help focus the questioning, even if you’re working from an existential perspective.

“Evidence-Based” Treatment

VY: As you’re a professor at the University of Montana, and actively involved in training students, I’m wondering what your thoughts are about the major trend towards “evidence-based” treatment? There are a lot of leading figures in the field who are critiquing this trend. John Norcross talks about evidence-based relationships, since research actually shows that most of the positive outcomes in therapy are based on the relationships and not on this or that technique or procedure. Are you pressured by accrediting agencies to teach evidence-based treatments? What have your experiences been in this regard?
JSF: Yes, there is a lot of pressure to incorporate “evidence-based,” or “empirically-supported treatments.” When you look at Norcross’ work, you have to shake your head and wonder why we focus so much on technical procedures and evidence-based treatments. The science just really isn’t there. There are studies done that show X or Y treatment is effective and, therefore, it becomes evidence-based. And yet there’s a mountain of evidence saying otherwise, that it’s not the specific protocols that make a positive treatment outcome.
There are these voices in the wilderness, like Norcross, crying out about this, but there’s still this inexorable trend towards requiring these evidence-based treatments in training students and in various government agencies, for example.
The cynical side of me would say it’s about trying to get our share of the healthcare dollars. Shaping ourselves to be in the medical model, since there are empirically-supported medical treatments. Of course, there is some real scientific evidence that we should be aware of when working with our clients. We should be, because we’re professionals in this area. Like Norcross writes about, there are evidence-based relationship principals that account for positive outcomes and so we need to look at those, and we need to emphasize those more than the technical procedures. There are evidence-based relationship principals that account for positive outcomes and so we need to look at those, and we need to emphasize those more than the technical procedures.
But we shouldn’t ignore all technical procedures because, even Carl Rogers would say, “If the technique arises spontaneously out of a particular place where you are in the counseling process, then it may be appropriate.”
VY: In wrapping up, any advice you would give for students or early career therapists just starting out?
JSF: I think my biggest advice these days is to focus on balance: The balance between the science and the art, the balance between the relationship and assessment and diagnosis. We need some diagnostic information in many real world situations, but we should not try to get that at the risk of damaging the therapeutic relationship. The impulse is for people to go one direction or the other. I was at a workshop one time where a woman referred to people as science “fundamentalists,” which I thought was a very apt description of some people. They have this allegiance to the paradigm of modernist science, and that’s the only way truth is known.
Then there are people who are much more touchy-feely and go with the flow. My general advice would be, if you’re more of a touchy-feely person, you really still need to learn the science. You still need to read the clinical interviewing text and understand the content that is our professional foundation. And if you’re more inclined toward scientific fundamentalism, you need to get out of that box and try to learn from the other side of the dialectic, which is the relational, emotional side of things that happen in the therapy office.

Advice for the Late-Career Therapist

VY: So let’s use mid- or later-career therapists as an example. By that time in their careers, many have migrated to private practice and have gotten very comfortable in their own ways of being with clients. In many ways that’s a good thing—it’s part of the career progression to take everything you’ve learned along the way and integrate that into who you are as a person. But one drawback I see is the possibility of just jumping into therapy with any client who walks in your office—assuming they’re a good fit for you—without maybe doing a proper assessment. And then they find out six months down the road that the client has a drinking issue that they hadn’t disclosed before. Any advice for these later-career therapists?
JSF: Yes. I’m not in full-time private practice right now but I have friends who see 35 people a week, and are doing the kind of thing you’re talking about.
It’s so easy for us to get into a little niche where we do it our way, and we’re no longer open to other ways of thinking. I’d say it’s really important to keep stretching yourself, to keep reading, to keep going to professional workshops, because we can do things wrong for years and think that we’re actually being successful.
Scott Miller is emphasizing it now more than anyone else–but it’s incredibly important to get systematic feedback from our clients so that we can get a sense whether we’re on the right track with each individual client.
Even though we sometimes can convince ourselves that we’re incredibly intuitive and we can, therefore, launch into therapy immediately, there is some research that suggests that negative outcomes correlate with inadequate assessment. So we do need to step back and do a little formal assessment here and there, even though, as experienced practitioners, we might think, “I know what to do here. This is not a problem.”
Instead, step back and to say, “Let’s do a little bit of assessment here so we can work together to make sure that we’re on the right track.” In other words, mid-therapy adjustments and assessments to make sure that we are helping our clients as effectively as possible.
VY: A final question: What’s your growing edge right now as a teacher and practitioner?
JSF: I have several growing edges. One growing edge that’s pretty constant for me is working toward greater cultural sensitivity, and being able to know more deeply about people who come from diverse minority kinds of backgrounds.
Another growing edge for me is the whole idea of mindfulness and how to incorporate that into some of the more traditional ways that I was taught to do psychotherapy.
I think the other growing edge for me is kind of a growing foundation. The person-centered principals for me have always been foundational and I find myself sometimes really wanting to go back to those. I can see myself in future months or years going to some trainings to get even better at the things that I think are my basic foundational skills.
VY: I often have the opportunity to review some old videos that we’ve acquired or produced and just recently watched the first video produced with James Bugental, a human-centered existential therapist. I’ve probably seen that video 20 times and I still appreciate it, perhaps on an even deeper level.Well, I want to thank you for taking the time to talk with us today.

JSF: Thank you very much, Victor. I very much appreciate your work and the fact that you have dedicated a lot of your life to making the work of other great therapists accessible to all of us.

Scott Miller on Why Most Therapists Are Just Average (and How We Can Improve)

Posted on by rezendevknowfully.com

Escape from Babel

Tony Rousmaniere: Many people know you as a Common Factors researcher, but recently you’ve transitioned away from that. Could you explain both what Common Factors is and your transition away from it?
Scott Miller: Sure. As old-fashioned as it sounds, I’m interested in the truth—what it is that really matters in the effectiveness of treatment. Early on in my career, I learned and promoted and helped develop a very specific model of treatment, solution-focused therapy. We had some researchers come in near the end of my tenure at the Family Therapy Center in Milwaukee who found that, while what we were doing was effective, it wasn’t any more effective than anything else. Now, for somebody who had been running around claiming that doing solution-focused work would make you more effective in a shorter period of time, that was a huge shock.
All models are equivalent. Pick one that appeals to you and your client.


It was at that point that I started to cast about looking for an alternate explanation for the findings, which concluded that virtually everything clinicians did, however it was named, seemed to work despite the differences. That led back to the Common Factors—the theory that there are components shared by the various psychotherapy methodologies and that those shared components account more for positive therapy outcomes than any components that are unique to an approach. It was something that one of my college professors, Mike Lambert, had talked about, but that I had dismissed as not very sexy or interesting. I thought, how could that possibly be true?

It was at that time that I ran into a couple of people that I worked with for some time, Mark Hubble and Barry Duncan, and we had written several books about this. If you read Escape from Babel, which we coauthored, the argument wasn’t that Common Factors were a way of doing therapy, but rather a frame for people—therapists speaking different languages—to share and meet with each other. They were a common ground.

But by 1999, it was very clear to me that Common Factors were being turned into a model by folks, including members of our own team, and viewed as a way to do therapy. But you can’t do a Common Factors model of therapy—it’s illogical. The Common Factors are based on all models. This caused a large amount of consternation and difficulty, numerous discussions, and eventually I suggested to the team that the way therapists work didn’t make much of a difference.

What was critical was whether it worked with a particular client and a particular therapist at a particular time. Mike Lambert was already moving in this direction and said, “Let’s just measure them. Let’s find out. Who cares what model you use? Let’s make sure that the client is engaged by it and that it’s helping them.” So we began measuring, and what became clear very quickly was that some therapists were better at it than others.

So, since about 2004, Mark Hubble and others at the International Center for Clinical Excellence (ICCE) have been researching the practice patterns of top performing therapists. It’s not that I don’t believe, and in fact know, that the Common Factors are what accounts for effective psychotherapy. It’s just that an explanation is not the same as a strategy for effecting change. And the Common Factors can never be used as such. All models are equivalent. Pick one that appeals to you and your client.

The Siren Song

TR: So Common Factors are a way of studying the effects of psychotherapy, but not a way of actually implementing it.
SM: Well, by definition, you can’t do a Common Factors model because then it’s a specific factor. I’m not saying the Common Factors don’t matter—what I’m saying is that they are a therapeutic dead end. They will not help you do therapy. You still have to have a method for doing the therapy, and the Common Factors are not a method. Why?
What I say is, pick one of the 400 that appeals to you and then measure and see: Does your client like it, too? If not, then it’s time for you to change, not your client.
All treatment approaches return equal efficacy when the data is aggregated and methods compared in a randomized controlled trial. So you still need some kind of way to operationalize the Common Factors.

Since we have 400 or so different models of therapy, why invent a new one? It seems to be because in our field, each person has to have it their own way. The promise of a new model is a siren song in our profession that we have a hard time not turning our ship towards. What I say is, pick one of the 400 that appeals to you and then measure and see: Does your client like it, too? If not, then it’s time for you to change, not your client.
TR: You have an article out in Psychotherapy where you mentioned three keys for therapists to improve their work. Your major focus now seems to be how therapists improve their work with each client. Can you describe those three keys?
SM: The first one is knowing your baseline. You can’t get any better at an activity until you actually know how good you are at it now. We therapists think we know, but it turns out that data indicates that we generally, as a group, inflate our effectiveness by as much as 65%. So you really have to know just how effective you are in the aggregate. That means you’re going to have to use some kind of outcome tool to measure the effectiveness of your work with clients over time.
We generally, as a group, inflate our effectiveness by as much as 65%.


The second step is to get deliberate feedback. So once you know how effective you are, then it’s time to get some coaching, get some feedback, and you can do that in two ways. Number one, you can use the very same measures that you used to determine your effectiveness to get feedback from your clients on a case-by-case basis. Meaning that you can actually see when you’re helping and when you’re not, and use that to alter the course of the services provided to that individual client.

The second kind of feedback to get is from somebody whose work you admire, who has a slightly broader skill base than you do, and have them look at your work and comment specifically about those particular cases where your work falls short. In other words, you begin to look for patterns in your data about when it is you’re not particularly helpful to people, and seek out somebody who can provide you with coaching. It’s like in golf, once you know what your handicap is you can hire a coach who can look at your game and make fine tweaks. It’s not about revamping your whole style, or about learning an entirely new method of treatment, but pushing your skills and abilities to the next level of performance.

The third piece is deliberate practice. The key word in that expression is “deliberate.” All of us practice. We go to work. But it turns out the number of hours spent on a job is not a good predictor. In fact, it’s a poor predictor of treatment effectiveness. So what you have to do is identify the edge of your current realm of reliable performance. In other words, where’s the next spot where you don’t do your work quite as well? And then develop a plan, acquire the skills, practice those skills and then put them into place. Then measure again to see, have you made any improvement?

I can’t take credit for coming up with these three steps. We’ve simply borrowed them lock, stock, and barrel from the performance literature, and in particular, Anders Ericsson’s work, which has been applied in fields like the training of pilots, chess masters, computer programmers, surgeons, etc. If we have any sort of claim to fame, it’s that we’ve begun applying these to psychotherapy for the first time.
TR: One of my first reactions to this is, aren’t some people just born better therapists?
SM: Well Ericsson notes that the search for genetic factors responsible for the performance of eminent individuals has been surprisingly unsuccessful. In sports we often think, “Oh, there must be some genetic component involved here,” or “he just has the gift of music.” But it turns out that virtually everyone that researchers looked at where the “gift” is implied, even with Mozart—he had been playing the piano for 17 years before he wrote anything that was unique, which happened at about age 21. He’d been playing since he was 4. His father had been doing music scales with him since he was in the crib. So once you remove the practice component, you just don’t find any evidence for genetic factors—with very few exceptions.

For example, in boxing it appears that people with a slightly longer reach have a slight advantage. But we also know that if baseball pitchers don’t start pitching at a particular age, their arms will not make the adjustment required to throw the ball as fast and accurately as professional pitchers do.

There was another study that looked at social skills. You often will hear, in addition to the genetic claims, that, “Good therapists just have great social skills.” Well, they’ve measured that. It turns out not to be the case, and the reason is that these kinds of ideas are too high or general a level of abstraction. The real difference between the best and the rest is that they possess more deep, domain-specific knowledge. They have a highly contextualized knowledge base that is much thicker than average performers, and much more accessible to them and responsive to contextual clues.

Deep Contextual Knowledge

TR: Could you give a specific example of what a deep contextual knowledge would look like in a therapy room?
SM: Well the classic one—and I say it to make fun of it—is suicide contracting. Or the suicide prevention interview.
Somebody comes in and says, “I’m going to commit suicide.” And we respond with, “Do you have a plan? Have you ever attempted this before?” Blah, blah, blah. That’s decontextualized knowledge. You could ask those questions to a stick.
Somebody comes in and says, “I’m going to commit suicide.” And we respond with, “Do you have a plan? Have you ever attempted this before?” Blah, blah, blah. That’s decontextualized knowledge. You could ask those questions to a stick.

What a top performer does is ask those questions very differently, nuanced by the client’s presentation, in ways that the rest of us can’t see. Because of their more complex and well-organized knowledge, they can actually see patterns in what clients present that the rest of us would miss and respond to in a much more generic fashion. Is this making sense?
TR: Absolutely.
SM: So the real question is how to help clinicians develop that highly contextualized knowledge. Because once you have it, not only can you retrieve that knowledge at the appropriate moment, but it turns out you can make unique combinations and use them in novel ways that would never occur to the rest of us, or would only occur to the rest of us by chance.
TR: This also doesn’t suggest that treatment manuals are necessarily the best way to train therapists.
SM: We know that following a treatment manual doesn’t result in better outcomes and it doesn’t decrease variability among clinicians using the same manual. So you still get a spread of outcomes, even when everybody is doing the same treatment.

At the same time, I think it’s critical that therapists learn a way of working, and, in the beginning at least, they hew to that approach. Why? Well, if you begin to introduce variation in your performance early on, you will not have the same ability to extend your performance in the future.

Let me give you an example. The first time I had a guitar lesson, I was taking classical guitar with this really interesting teacher. We spent the entire first lesson on how he wanted me to hold the neck of the guitar with my left hand—and I’m right handed. He said, “If you try to vary your hand grip from the outset, you’ll never have the same reach and ability to vary reliably when you need to in the future. So start with a common foundation, and then when we need to introduce variations later, we will.” My sense is that therapists instead begin in a highly complex, nuanced way and introduce variations into their style randomly and without much thought.
TR: So it would be better to begin with a frame or structure that provides a stable base, and then develop the deep contextualized knowledge later on.
SM: And to vary your work in ways that allow you to measure the impact of your variation against what you usually do. This is the key. Otherwise, what you have is a bag of tricks. You can do them all, but there’s no cohesiveness to it, and you can’t explain why you vary at certain times rather than others.
TR: Starting with a manual isn’t necessarily a bad idea then.
SM: Absolutely not. In fact, I would suggest grabbing a manual and going to a place where they are teaching a specific approach that will allow you to practice and also watch others in a two-way mirror. Once you have that foundation down, you can introduce your own variations.
TR: I hear therapists say, “I have 20 years experience,” or “I have 30 years experience.” Does this research find that experience, itself, makes someone better?
SM: No, it doesn’t. We know that not only in therapy, but in a variety of activities. If you think about it, you’ll understand why. While you’re doing your work, you don’t have time enough to correct your mistakes thoughtfully.
The difference between the best and the rest is what they do before they meet a client and after they’ve met them, not what they’re doing when they’re with them.
So what we found, which I think is quite shocking, is that the difference between the best and the rest is what they do before they meet a client and after they’ve met them, not what they’re doing when they’re with them.  Let me give you an example from a field that is similar—figure skating. If you watch a championship figure skater perform a gold medal winning performance, you can describe what they did, but it won’t tell you how to do it yourself. Do you follow me?
TR: Yeah.
SM: In order to be able to accomplish that performance, that figure skater must do something before they go on the ice, and after they leave the ice. It’s that time that leads to superior performance. You can go out and try to turn triple axels during the performances as much as you want. That experience will not make you better. You have to plan, practice, perform, and then reflect. Most of us don’t see all of the effort that goes into that great performance. We just appreciate how good it is.
TR: But one of the tricky differences is that we’re trying to help each client. And if we’re practicing new skills, invariably we’re going to make mistakes. And that’s emotionally harder because you’re making a mistake with a real person sitting across from you.
SM: Well, number one, we’re all already making these mistakes. And the ones that I’m referring to are generally small and not fatal. So your performance doesn’t improve by isolating gross mistakes, or gross skills. Your performance improves when your usual skills begin to break down—meaning they don’t deliver—and remembering those, thinking about them after the session, and making a plan for what to do instead. That’s where improvement takes place.

When I hear people mention this kind of objection, I think they’re thinking that the errors are far grosser than what I’m talking about. Once therapists assess their baseline, most are going to find out—to their, perhaps, surprise—that they’re average in terms of their outcome, or slightly less than average. So if we’re average, then it’s not about bringing your game up to the average level. It’s about extending it to the next. That requires a focus on small process errors.

Let me give you another example. We have a pianist come and perform at one of our conferences. She is eight years old and she is really unbelievably able as a concert pianist. She plays a very difficult piece. I ask her if she made any mistakes. She says, “Of course, I made a lot.” I tell her I didn’t hear any, to which she says, “Well, that’s because you’re no good at this.”

I then say, “What do you mean? And what do you do about your mistakes?”

She says, “Look. I made lots of mistakes, but you cannot get better at playing the piano while you’re performing.” This is an 8-year-old.

I say, “So what do you do?”

She says, “Well, I hear these small errors. I remember them. My coach in the audience remembers them, and then that’s what I isolate for periods of practice between performances.”

Most of Us Are Average

TR: How many therapists really practice between sessions? I mean, that’s pretty rare, isn’t it?
SM: Most of us are average.
TR: Right.
SM: And 50% of us are below average, right?
The best performers spend significantly more time reading books and articles….and reviewing basic therapeutic texts.
So very few people do it, and this is the real mystery of expertise and excellence. Why do some go this extra mile? There’s no financial pay-off. I think this will change in the future, but at the present time, you don’t get paid one dime more if you’re average, crappy, or really good. The fees are set by the service provided.
TR: That is a great problem with our field and I hope that does change in the future.
SM: I think that we’re seeing movement in that direction. I think that our field will become like other fields, where outcome of the process is what leads to payment, rather than the delivery of it.
TR: So back to practicing. Therapists read books and go to workshops, but that’s kind of passive learning. What are your thoughts about that?
SM: That’s a component of practicing. A graduate student that I’ve been working with, Darryl Chow, who just finished his PhD at University of Perth in Australia, did his dissertation on this topic and found that the best performers spend significantly more time reading books and articles. We also know that the best performers spend more time reviewing basic therapeutic texts.

Therapists are often in search of the variation from their performance that will allow them to reach an individual client they’re struggling with. Top performers not only do that, but they’re also constantly going back to basics to make sure they’ve provided those. They spend time reading basic books that may be hugely boring but are nonetheless really helpful. Gerard Eagin’s The Skilled Helper, Corey Hammond’s book on therapeutic communication—these basic texts that remind us of things that we often forget in the flurry of cases we see every week.
TR: So reading counts. What about workshops?
SM:
We don’t know about workshops. I’m cynical about them, simply because they’re not set up in a way that respects any principles of the last 30 years of research on human learning.
We don’t know about workshops. I’m cynical about them, simply because they’re not set up in a way that respects any principles of the last 30 years of research on human learning. Six hours, chosen by the person who needs the continuing education, and there’s no testing of skills, acquisition of skills, no awareness of particular deficits in practice. Greg Neimeyer has done a fair bit of research on this and he finds no evidence that our current CE standards lead to improved performance. None.
TR: There’s a psychotherapy instructor I know, Jon Frederickson, who has his students go through psychotherapy drills, kind of like role-playing drills in a circle. Would that count as practice?
SM: It depends, but I like the sound of it. Not a scrimmage, where you do a whole game, but rather drilling people in very specific small skill sets again and again. That aligns with the principles of Ericsson’s researchers.

If you’re an experienced professional, your motivation for going to a CE event can be really varied. I know for me, I’m often just grateful to have a day off and hang out with friends. The particular content of the workshop, I’m ashamed to admit, is less important. The incentives are just all wrong.
TR: It goes back to your motivation question.
SM: I don’t think our field incentivizes that kind of stuff. In fact, you can be punished.
TR: Well, one incentive I discovered myself in my own private practice was my drop-out rate. That motivated me to get further training. Maybe other therapists don’t have the same problem I had, but I know that was a powerful motivation.
SM: Drop-out can be both a good and a bad thing. For example, our current system incentivizes therapists to have a butt in the seat every available, billable hour. What that means is that therapists may be incentivized—we have some data about this, too—to keep clients, whether they are changing or not. That’s what I mean when I say that the incentives are all screwed up. There are, every once in a while, motivated people like yourself who say, “Wait a second. There has to be something beyond this.” But that requires a degree of reflection that may be difficult for most of us, especially if we are well defended. For these folks, people drop out because they are in denial about their own problems, not because of anything they, themselves, might be doing.

You put those things together and it can be a fatal combination. We need to take a step back as payers for services and as consumers of services and think about the incentives in our current system. I know this sounds terribly economic, but I think it’s important for our field.
TR: That sounds sensible to me. What about watching psychotherapy videos by psychotherapy experts like the ones psychotherapy.net produces. Would that count as practice?
SM: Yes it would. Especially in the beginning, when you have identified a particular area or weakness in your skill set that you may need some help with. In essence, you’re spending more time swimming in it while reflecting, which is the key part.
TR: Do you have other examples of deliberate practice that you’ve heard of therapists engaging in?
SM: Well there’s the stop-start strategies that Darryl Chow has been talking about. And Chris Hall is doing a study at UNC that we’re involved with, where therapists will watch short segments of a video and then they have to respond in the moment in a way that is maximally empathic, collaborative, and non-distancing. So they’re training therapists to develop a certain degree of proficiency with fairly straightforward clients.

Then you begin to vary the emotional context, or the physical context, in which the service is delivered. So now the client’s not just saying, “Hey, I feel sad.” They’re threatening to drop out or to commit suicide. More difficult and challenging things. And then simply spending time outside of the office planning and discussing individual particular cases with peers or consultants is another strategy.

In Darryl Chow’s research, which I think is the most exciting stuff, he found that within the first eight years of practice, therapists with the best outcomes spend approximately seven times more hours than the bottom two-thirds of clinicians engaged in these kinds of activities. Seven times.
TR: Wow.
SM:
The key to this is really starting early and investing a little bit at a time. It’s sort of like how you’re advised to save for your retirement. Not in the last five years. Not in the first five years, but a little bit every year.
The good news is, now that we know this, we can start this process earlier. The bad news is, if you’ve been at this for awhile, it becomes impossible to catch up with the best. We just age out. We can’t do it. The key to this is really starting early and investing a little bit at a time. It’s sort of like how you’re advised to save for your retirement. Not in the last five years. Not in the first five years, but a little bit every year.
TR: One advantage that great athletes have is that their coaches gets to determine day by day what moves or what performances they’re going to practice. I run a training program here at University of Alaska, Fairbanks, at the University Center for Student Health and Counseling, and I don’t get to pick what clients come in day to day. It could be anxiety, depression, any number of different things, so I’ll do a training on, let’s say, working with anxiety, but the client that comes in will have depression. So what do you do about that?
SM: Well, in essence, we’re violating John Wooden’s primary rule, which is, we are allowing students to scrimmage before they drill. And I have to tell you, all students want to scrimmage, but what you need to do more of, before and during, is drilling. The kind of drilling that I think your colleague was talking about. Or you go back to, “Here’s how we hold the guitar.” And we play very simple songs and then we begin varying the drill with greater degrees of complexity once easier tasks are managed.
TR: So you’d recommend a longer period of training and practice and drills before seeing clients.
SM: I’d want to see that kind of mastery. Let me give you an example. Do you want the pilot to be proficient at flying in fair weather, as demonstrated on the simulator, before they fly a plane?
TR: Yes.
SM: You want them to be prepared for all the complications: “Wait a minute, it’s raining,” “Wait a minute, you’ve got problems with your rudder.” These are complex skills and, yes, we can teach people to manage them as one-offs, but then they never integrate it into a coherent package that makes it easier to retrieve from memory later on when they need that skill. If it’s viewed as a one-off—“With the anxiety client, I did this”—it’s not integrated into an organized structure for retrieval later on.
TR: So on a therapist’s resume, you’d want to see not just hours of direct service provided, but also hours spent practicing and learning.
SM: Or, better yet, somebody who has measured results, like yourself. All I need is an average pilot. I don’t need the best pilot in the world, because most of the time there’s not huge challenges. If you can document your results, and if you’re checking in with me, we’re going to catch most of the errors anyway. And then I want a therapist who has a professional development plan, that’s working on the aggregation of small improvements over a long period of time.
TR: So for tracking results, I know you recommend quantitative outcome measures, like the Outcome Rating Scale or the Outcome Questionnaire. But I have found that there are certain clients that quantitative measures just don’t seem valid for. It’s not a large percentage of clients, but there are some that underreport problems at first. So it can look like they’re deteriorating even while they’re improving. Can you recommend any kind of qualitative methods or other methods of trying to accurately assess outcome in addition to those measures?
SM: I don’t buy it. Personally, I just don’t see that stuff and I would offer a very different explanation for it. Let me give you an example.

We know that each time there is a deterioration in scores, the probability of client drop-out goes up, whether or not the therapist thinks that it’s a good sign that the client is “getting in touch with reality and finally admitting their issues,” or had inflated how they really were doing for the first visit. So the key task here is not to say, “There must be another measure,” but to figure out what skills are required for me to get a higher score.

Dig Into the One You Know

TR: That’s a new perspective. To look at what I can change about my performance, rather than a new measure to assess it.
SM: Now you see why I think our field is forever chasing its tail. Because instead of becoming fully connected to our performance, we are constantly looking for the trick that will make us great.
Instead of becoming fully connected to our performance, we are constantly looking for the trick that will make us great.
It’s like a singer looking for the song that will make them famous rather than learning how to sing. We’re forever going to workshops, and the level of the workshops are often so basic even when they’ve claimed to be advanced. The truth is, you can’t do an advanced workshop on psychotherapy for 100 people. You can’t do it. The content is too abstract and too general. You need to see a clinician’s performance and fine-tune it. So therapists go around and around, constantly picking up these techniques that they use in an unreliable fashion, and their outcomes don’t improve, but their confidence does.
TR: So instead of picking up a new modality every year, dig into the one you know, preferably with a real expert, and get individualized or maybe small group training and practice.
SM: I think that once you’ve achieved a level of proficiency, the only hope for improvement is to get feedback on your specific deficits. And yours will be different from mine.
TR: It sounds like you’d definitely be a fan of videotaping sessions and reviewing them and that kind of thing.
SM: Not alone—with an expert eye reviewing small segments. Otherwise the flood of information from video will have you second-guessing yourself, which can actually interrupt the way you work in an unhelpful way.
TR: What about live supervision?
SM: I’m not averse to it, but I think it’s a little bit like a GPS—it can correct your moves in the moment, but you become GPS-dependent and you don’t learn the territory. What’s required in learning is reflection. If you don’t reflect, you can’t learn. As my uncle used to say, “You got to study that thang.”

I actually had great opportunities with live supervision when I was at the Family Therapy Center and got corrected in the moment by two really masterful clinicians. But I also think that what really made a difference was sitting behind a mirror, without any financial worries, watching endless hours of psychotherapy being done, and then talking about it afterwards. “This was said. What could you have said? How come we said this? What do you need to do?” It was a heavenly experience and as a result, I came away with a very highly nuanced and contextualized way of delivering that particular model.

And today, when I’m doing my Scott Miller way of working and I notice that a particular client wasn’t engaged or interested at a particular moment, I think, “What could I have said differently?” It’s at that small micro level that improved outcome is likely to be found. As opposed to just gross generic level.

People go to workshops and say, “I’ve had some traumatized clients. Maybe I’ll learn that EMDR thing.”

“Really?” I think. “Do you know how effective you are in working with these clients already?”

“No, I don’t.”

“What makes you think you need to do EMDR?”

“Well, it just seems so interesting.”

And I think, “Oh, you’re doomed.” Not that there’s anything wrong with EMDR, but I have to tell you, I watched Francine Shapiro do it and it looks a lot different than some other people I’ve seen doing it.
TR: So the problem there is switching modalities rather than getting a lot better at the one you’re currently using.
SM: It’s looking for a trick rather than thinking through, what else could I have said? What else could I have done that I already know how to do? Or getting a little bit of tweaking from a trusted mentor.
TR: I know you present this information all over the world. Do you find therapists are open and receptive to these ideas?
SM: Yes. I think that there are some very real barriers that we need to address, but yes, I do.
TR: This has been a really fascinating conversation. Thank you for making the time.
SM: I like this stuff. I’m fascinated by it and I’m very hopeful about the direction we’re going research-wise, so thank you for giving me the opportunity.

Jean McLendon on the Legacy of Virginia Satir

Posted on by rezendevknowfully.com

Clock Watchers

Jay Lappin: So, Jean, the first thing I want to ask you is, what can Virginia Satir’s family therapy offer to new therapists? What could young therapists entering the field learn from the model?
Jean McLendon: Well, I find myself wondering, what can the more experienced therapists learn from the model? New therapists who have not been in the room with a client or a patient, or have done very little work, don’t have much of a context or framework for how to even be in the therapeutic interaction.

Just recently I heard that a young therapist asked if it was okay to have a clock in her room, and if so, should the clock be visible just to her or to her and the client? I was floored that someone who was finishing their graduate degree was concerned at all about that. I responded in a way that I didn’t particularly like because I was so astounded by the question. Theoretically I believe that all questions are good questions, but this one led me to think, what is this person learning about the importance of authenticity, of connection, of working with the client, not on or for the client.

I think the worry behind that question is, “I don’t want my client to think that I’m only watching the clock and that I’m not interested in what they have to say,” or something like that. But the clock is not going to give people a message one way or the other, or if they make a meaning of it you have no control over that. My sessions are 45, 50 minutes and I definitely want my clients to have access to the same clock I’m using. Why would I not? So being able to say, “Since we only have 45 minutes, I’ve got a clock here. We can both keep our eyes on it,” or, “I have a clock. I’ll let you know before the 45 minutes is up,” is thoughtful, it's considerate, it is sharing useful information.

Virginia was very astute about engaging clients in the here-and-now, in the room, sharing her thoughts and participating with them.
Virginia was very astute about engaging clients in the here-and-now, in the room, sharing her thoughts and participating with them. So she might say, “I don't want the clock to bother you. We can turn it towards me.” Or, “Would you like to have the clock so that you can see it too?” But to ask the question, “is it okay to have a clock in the office, is it okay if the client knows you have a clock?” I fear there's a whole basis of skill and belief about humans and communication that just isn’t reaching these students.
JL: For many of the young people that I supervise, it's very much a business model for them, and with the advent of evidence-based therapies, people are leaning more in that direction. So some of those human elements that Virginia brought to the field are now right alongside “beat the clock” and cramming as many people in as possible in a day, and really more of a manualized approach. And if you want to secure funding for research, you pretty much have to promise something “evidence-based.”

But one of the things I know from reading Virginia’s work and watching her work over the years is that she just has this way of connecting with people that seems entirely un-manualized. So human and so connected. How do you teach that in today’s context of evidence-based therapies?
JM: I would love for you to ask me in about four or five years, because right now I don't know how to integrate the two. I am teaching Satir family therapy with the University of North Carolina substance abuse and addictions outpatient program and they are finding it marvelously effective and have been able to secure funding for me to continue teaching because the results are so positive. But we’re not doing research on it yet.

I had a supervision group years ago, and I was doing family mapping, which for me is basic to Satir work. Because the family of origin experience is, as I like to think of it, the first PhD we get in life.
The family of origin experience is, as I like to think of it, the first PhD we get in life.
My family maps don’t look particularly like genograms, or at least not traditional ones—they are colorful, a little too messy, more pictorial. It’s a visual aid for the client and for me to appreciate the real narrative of where they have come from and what they are hoping for, and what they are dealing with in their life now.

I don’t have them color-coded, but I might have very strong red zigzag lines between people to show conflict, or very distanced dots to show a weak relationship, or lines that show cutoffs. If it’s a couple, I’ll have her comments in one color and her partner’s in another color. It’s just very colorful.

So I do the family maps as part of supervision because I also believe the places we tend to hit a wall as therapists also have their roots in our family-of-origin experience. You know, what are the basic defensive structures and ways we have of protecting ourselves? We keep those for life and even though we can work on them, it's like gravity—they are kind of always there. They are insidious, unless we are aware of them.

Anyway, this PhD clinical psychologist comes back two weeks later, and I’m hoping that they've all done a family map with a client, and she says, “I did one but I couldn’t remember which color you used for what.” I thought, "Well, this is reflective on you, Jean. You are not a very good teacher."

Wet Cocker Spaniel Therapy

JL: It reminds me of that old Frank Pittman article called “Wet Cocker Spaniel Therapy.” He wrote it when he was doing the Denver research about home-based services for emergencies, for families to keep the patient out of the hospital. The story is very much like what you said. This woman is having problems. They go to her house and she’s lying on the floor, refusing to get up. She won’t talk, and they are trying to think of all these clever strategic moves to get her up and moving, and keep her out of the hospital.

The family dog is outside and it’s raining, so the husband lets the dog in. The dog is soaked. It comes in and just kind of shakes himself, so all this water and mud and stuff goes flying and gets on the woman. And she sits up and says, “Oh, the heck with it, fine, I won’t go to the hospital. I’ll talk to you.” Frank’s point was, does that mean that we need to have wet cocker spaniels for all of our work, to keep people out of the hospital?
JM: I think that's the challenge. People watch those of us who are experienced—and particularly in the Satir model, where we work fast in the here-and-now, whether it’s through sculpting or finding ways to externalize an internal challenge in ways that are helpful for particular clients. How we do these things looks like the methodology, but it's really just executing and implementing something out of a very potent belief system about people.
JL: What do you think Virginia would say to today’s therapists about how to use oneself in therapy? Because really what you're talking about is the use of self and that kind of inner knowledge of one’s defense mechanisms that might get in the way of helping other people connect with their family members in more vital ways.
JM: I think she would be conveying her belief in the power of positive connections and promoting a kind of synergy that enhances a creative resourcefulness between and among people. She models and guides that kind of interaction in the office that helps set it in motion and helps people first experience it and then begin to learn the skills of doing it.

One of the addiction therapists I worked with asked, “How do you know in Satir work when the work is done and you can terminate?” I hate that word, but I said, “Well, there's nothing wrong, if you can afford it, with doing Satir work for the rest of your life, because it's all about growth and healing.” It’s rather luxurious, and most of us are not going to choose to use our resources in that way, but I believe there's always room for more growth.

Becoming More Fully Human

JL: What are some of the other nuts and bolts of the model?
JM: In a sense it's a kind of psychosocial educational model that aims to help people create the kinds of relationships that support them in terms of emotional, physical, psychic, and spiritual health. It’s also about helping people take ownership for themselves and take responsibility for the choices they make.
It's a kind of psychosocial educational model that aims to help people create the kinds of relationships that support them in terms of emotional, physical, psychic, and spiritual health.


I see it played out so often in my couples work, where she thinks that “If only he would do X, then I could do Y.“ Getting people to release their spouses, their parents, from being responsible for what they feel and for choices they make is so critical to helping people figure out what changes they need to make. So I put an increase in self-esteem, congruence, responsibility, and ownership for self up there at the top. All of that helps people, as Virginia said, become more fully human.
JL: One of the things that I remember her saying was, ”The family is a microcosm of the world.” That if you know how to heal the family, you know how to heal the world. And Sal Minuchin, back in the early days of family therapy, said that we could change the world one family at a time.

But he recently told me, “We were wrong.” And what he meant was that you really need to think in terms of larger systems as well, as that is a huge context, particularly when from a structural perspective we work with a lot of families that are poor. The context that they live in, and how agencies work with them, has a huge impact on the structure of the family and how all of these goals are realized.

Could you say a little bit more about taking Virginia’s work into a larger context? I know that you’ve been very involved in helping larger systems adopt some of these principles.
JM: It’s one of the reasons I was so initially attracted to the Satir model. There are two reasons, actually. One is that Virginia was talking about being and what it meant to be human in ways that made absolutely perfect sense to me in terms of my own internal experience, but I never heard anybody talking about it.

And secondly, it seemed obvious to me that she was talking about humans in contact with other humans, but she didn’t differentiate between the family therapy session or the boardroom, the church or Congress, because she basically split the universe into three pieces—she could take things that were very complicated and make them very simple. She said this is what you have to deal with: Yourself at a given moment in time, the “other," whoever that might be, and the context in which the relationship resides.
She didn’t differentiate between the family therapy session or the boardroom, the church or Congress.


So how do we create the most supportive context for the self and the other? Well, ask anybody, any group on the planet, “What kind of behaviors make it easier for you to learn, and to enjoy, and to feel that you can be productive and can contribute? What kinds of behaviors interfere with that?” And you'll find out, of course, that people don’t like to be put down. People don’t like to be interrupted. People like to have their opinions valued, even if not agreed with. It’s very basic. And yet, go into any of these contexts and you’ll see people being put down, ignored, excluded, humiliated, shamed, embarrassed. Not being welcomed.

About the third week into my first month-long with Virginia, I came in early one morning before breakfast and I knocked on the door. I was so excited. And I said, “Virginia, I’ve got it. I think I’ve figured it out.” And she said, “What do you mean?” And I said, “Well, what you were talking about, it's all about the universality of emotionality.” And she said, “Yes,” and went on brushing her hair or something. But it felt so big to me, because everything made sense within that context of being fully human. What our basic needs are at a moment in time, in order for us to feel in contact with our real value, our uniqueness, and the resources that we have inside of us to bring into expression with another person.

It’s not enough for me to know that I’m a valuable human being. At some level, I have to give expression to that. I have to share myself in the world and I do that by way of my relationships. So, how we share that in various contexts across cultures is so important. Virginia talked about the importance of peace within and then peace between people, and then peace among. Moving out into the world and doing the work in a larger context across cultures is peace among.

I worked with a man who has done a tremendous amount of work, including Virginia’s work, with people in the IT world. He and I did 7-day leadership workshops for a number of years, and 95% of the people were IT people.

Satir for Techies

JL: Were 95% also men?
JM: Well, I’d say 85% at least. Which was very different for me, because most of my teaching was with therapists and human service folks, who are 85% to 90% women.
JL: That must have been something, to have that change in gender context.
JM: It was fabulous. They have different learning styles. About 5 years into that, I began bringing them into a year-long performance development program that was Satir-based.
Human is human. We might use different words, we might dress differently, we might be a different color, but our basic innards are the same.
A therapist from Florida came in and she stood up and kind of stammered shyly that if she had known that she was going to be doing this training with non-therapists, IT people, she would not have signed up.

And I thought, “Jean, you were pretty naive.” But she signed up to do it the next year because it was so enriching, and that validated for me that people can be so very different, but ultimately we’re so alike. Human is human. We might use different words, we might dress differently, we might be a different color, but our basic innards are the same.

Positrons and Negatrons

JL: And now she can probably reboot her iPhone.
JM: No doubt, yes. It was helpful on many levels.

Satir, like me, felt that you could change the world one family at a time, but what Jerry Weinberg, the computer scientist who writes and teaches about the psychology of computer programming, said to me in relation to changing organizations, is that it's one individual at a time.

And I think that is also true. There are things that can be done formally at policy levels and through interventions from leaders to change context and to make them more human, but it really is true that in a sense, it's one individual at a time. In a family, it's one individual at a time. And I can only communicate and be in contact with one person at a time. My eyes go to your eyes and if there were others in the room my eyes could only meet them one at a time. Virginia did that beautifully.

Pure contact for humans is at a moment in time, with one other person. And it is the energy that comes out of the congruence between two people that helps people shift and change context. Congruence puts what I call “positrons” into the environment; incongruence puts “negatrons” into it.
JL: Can you say more about that?
JM: Well, I made those words up, but everybody knows what they mean. Positrons are connected to what I think of as the positive family-of-origin trance state, and that's a state of being where I belong, I feel secure, I feel valued.
In the negative family-of-origin trance state I don’t feel valued, I don’t feel seen, heard, known or understood and I emit negatrons, defensive incongruence.
In the negative family-of-origin trance state I don’t feel valued, I don’t feel seen, heard, known or understood and I emit negatrons, defensive incongruence.

When we are in the positive trance state, we feel energetically different. When I say to an audience, “What I’d like for you to do is just for a moment, close your eyes and position yourself in a way that would reflect to the outside world what it's like for you when you feel less than, or when you feel unseen or unappreciated,” their bodies get very contorted. Heads are down. Shoulders are sloped. Sometimes people ball up their fists. The body responds. That's why I think of it as a trance state. It’s not only about the kinds of thoughts you have or the feelings you have, but what's going on in your body, too.
JL: When people come out of that powerful body experience, what do they usually say?
JM: Well, it's very familiar to them. It’s not strange. In a sense, it's just kind of second nature. I give them permission to exaggerate it just so that they can bring it into their awareness. But if you can stay tuned to your body, your body can also tell you, “I’m not feeling very valued right now. What do I need to do, in the relationship with myself or with others, to bring myself into a kind of attunement?”
JL: As you're saying this, I think about how Virginia was very much ahead of her time with what are now called mindfulness practices. Back in the day it was considered kind of a tree-huggy, mossy non-scientific encounter, but these days it’s everywhere and there are scientific studies coming out all the time about its effectiveness. Can you say a little bit about the ways in which Virginia’s approach was similar or different to what we now know as mindfulness practices?
JM: Well, we knew back then it was not about fluff. Those of us who were getting trained as therapists back in the ‘60s, ‘70s, and ‘80s were learning experientially, so we knew what worked and what didn’t. We knew that experiential work and right-brain symbolic work could take us to places that we couldn’t get to in linear, didactic learning methods. It was also about therapists learning to use themselves. How do I put myself in a space where I am open, I am fully present, I am fully attentive, and available to the family or the client that I’m sitting with?

So we knew its value, and when we used it with our clients, they knew it its value. Maybe the scientific world or the academicians who weren’t using experiential models didn’t know it, but thankfully it has been affirmed and validated by research. Today’s mindfulness work is nothing new, but I think mindfulness training is an excellent way for therapists to be able to move themselves into an open, centered, and at-peace place inside of themselves in preparation to meet someone who’s going to come into their office who is not in a state of peace, but in a state of agitation and possibly feeling threatened. I remember
Virginia said that to feel that you need help, and to ask for it, and to seek it, may be one of the highest forms of congruence.
Virginia said that to feel that you need help, and to ask for it, and to seek it, may be one of the highest forms of congruence.

So people are coming in with that. They may not be able to say, “It really scares me to come in and talk with you. I don't know you. I’m accustomed to doing things on my own,” but I just know that they're likely coming in a state of some level of agitation and that I don't want to add more agitation to that. I don't want to add my anxiety to theirs. I don't want theirs to become mine. So, getting into a positive and solid relationship with myself and staying there is going to make me a much more empowered resource for my clients.

Mission Impossible

JL: Along those lines, could you say a bit more about self-care as a therapist? Because we know that there is a real thing called vicarious traumatization. Sitting with people in that spot with that kind of energy has its own drain on the therapist. What are some ways that people using the Satir model renew and reenergize themselves and continue to be helpful to their clients?
JM: I think the most important thing within this model is for me to believe that everyone who comes into my office has the internal resources to catalyze and to move towards growth and humanity. That takes me off the hook. I don't have to give it to them. I don’t have to give them courage. I don't have to give them a sense of curiosity. I don't have to give them a sense of, or an ability to care deeply about themselves or someone else.

I find new therapists wanting to give these resources to the client, as though the client doesn’t have them.
If I don't believe that my client is fully resourced, I have to take on a huge level of responsibility and burden, and that is mission impossible.
If I don't believe that my client is fully resourced, I have to take on a huge level of responsibility and burden, and that is mission impossible. I think it wears young therapists out. People who don’t learn how to deal with this don’t stay in the profession long. They go into policy or administration or whatever.

Interestingly, some people—I don't know whether they are born this way or how it happens, I’d love to—just have more resilience in their boundary systems. But again, my belief is that to the extent that you see, and know, and believe in the resources of your clients, it makes a huge difference in the burden and the drain that can come from being a therapist over time.

In terms of the vicarious nature of dealing with trauma, other people’s trauma, all day, I think supervision is a tremendous resource for therapists to get support. And of course therapists have their own traumas, so they have to be careful that they are not being triggered and ignoring that in their own process.

Another key is having a life outside of yourself as therapist. I think it's easy as therapists to be flattered or seduced by the way in which some clients express their gratitude for the help you give them, so it's really important that we are in the world relating to people who are not therapists and who are not our clients. It keeps us grounded and fresh.

The other thing I would say is, I think it's really important that therapists be involved in some kind of regular physical exercise, because I think the body needs to discharge those energies also. You sit all day and listen, and you need at some point during the day to exercise that body vigorously, to sweat.
JL: So, things like a good brisk walk on the beach, chasing down your dog?

JM: Absolutely. I can recommend also putting a dog in your office.
JL: As a co-therapist!
JM: Absolutely. He’s only growled at three people.
JL: Today?
JM: To date, he’s only growled at three. And thankfully, he makes up very quickly.

I’ve been working as a therapist for over 45 years, and people say, “Aren’t you ready to get out of it? Aren’t you tired of it?” And I can tell you, because of the model that I work from, I do not feel innervated. I do not feel drained. I do not feel burned out. The problem for me is that I continue to find people very interesting. And though I like being on the beach and I like gardening,
I am content to do this work for as long as it makes sense. I feel it is a privilege. I feel it is interesting work. I’m paid plenty well enough. And it's just a joy.
I am content to do this work for as long as it makes sense. I feel it is a privilege. I feel it is interesting work. I’m paid plenty well enough. And it's just a joy.

And I absolutely believe that it is not because of who I am, but rather the belief system and the model that taps in and activates my humanness in a very positive kind of way. So that, as I put myself in a position to enter somebody else’s world, and they join me and I join them on this journey, we are both enriched. I just don’t think that there's anything any better.
JL: I agree. We’re lucky to be in the profession we are. And I think you should continue to do what you're doing, because just listening to you today is energizing and hopeful, and gives me the sense that we can figure this stuff out if we all work together. Thank you so much, Jean, for your time. It’s been great.
JM: You're welcome, Jay.

Through the Anger Looking Glass

Posted on by Psychotherapy.net Team

On this past Sunday’s broadcast of “Weekend Edition” on National Public Radio, the focus was on the 50th anniversary of Betty Freidan’s The Feminine Mystique. In this book Friedan raged against the status of women in the 1960s. Although millions of people have read this feminist manifesto, it seems very few presently understand how anger in general and Friedan’s anger in particular could be a source of insight, motivation, and personal and social transformation.

Anger is an emotional state that has a bad rap. There’s far more written about anger control than about how anger, when nurtured and examined, can transform. As most mental health professionals already know, anger is an emotion, not a behavior. And emotions are acceptable and desirable. When anger fuels aggressive or destructive behavior is when it becomes problematic.

But since everyone knows about and talks about the destructive capability of anger—let’s talk about the constructive side of this emotion instead. Hardly anyone articulates anger’s positive qualities as clearly as the feminists. Feminist therapists consider “encouraging anger expression” as a meaningful process goal in psychotherapy for at least five reasons:

  1. Girls and women are typically discouraged from expressing anger directly. Experiencing and expressing anger without repressive cultural consequences can be an exhilarating freedom for females. Similarly, experiencing anger, but not letting it become aggression is a new and productive process for males.
  2. Anger illuminates. There’s nothing quite like the rush of anger as a signal that something is not quite right. Examined anger can stimulate insight.
  3. Alfred Adler suggested that the purpose of insight in psychotherapy was to enhance motivation. Anger is helpful for both identifying psychotherapy goals AND for mobilizing client motivation.
  4. During psychotherapy anger may occur in-session towards the psychotherapist. Skillful therapists accept this anger without defensiveness and then collaboratively explore the meaning of their in-session anger.
  5. Anger is a natural emotional response to oppression and abuse. If clients consistently suppress anger, it inhibits them from experiencing their full range of humanity.
For feminists, one goal of nurturing and exploring client anger is to facilitate feminist consciousness. Feminist consciousness involves females (and males) developing greater awareness of equality and balance in relationships. However, using anger to stimulate insight and motivation is useful in all forms of therapy, not just feminist therapy.

But working with (and not against) anger in psychotherapy is complex. The problem is that anger pulls so strongly for a behavioral response. Reactive anger is destructive. Clients want to let it out. Experiencing and expressing anger feels so intoxicatingly right. Clients want to punch walls. They want to formulate piercing insults. They want to counterattack. Unexamined anger is reactive and vengeful.

Imagine a male client. He’s uncomfortable with how his romantic partner has been treating him. You help him explore these feelings and identify the source; he recognizes that his partner has been treating him disrespectfully. But good psychotherapy doesn’t settle for simple answers. His new insight without further exploration could stimulate retaliatory impulses. Good psychotherapy stays with the process and examines aggressive outcomes. It helps clients explore alternatives. Could he be overreacting? Perhaps the anger is triggering an old wound and it’s not just the partner’s behavior that’s triggering the anger?

Relationships are nearly always a complex mix of past, present, and future impulses and transactions. When anger is respected as a signal and clients take ownership of their anger, good things can happen. It can be used to help clients become more skilled at identifying and articulating their underlying sadness, hurt, and disappointment. Clients can emerge from psychotherapy with not only new insights, but increased responsibility for their behavior and more refined skills for communicating feelings and thoughts without blaming anger, but in a way that serves as an invitation for greater intimacy and deeper partnership.

None of this would be possible without the clarifying stimulation of anger and a collaborative psychotherapist who’s able to help clients face, embrace, and understand the many layers of meaning underneath your anger. And it’s about time we learned a lesson from the feminists and started giving anger the respect it deserves.

Tara Brach on Mindfulness, Psychotherapy and Awakening

Posted on by rezendevknowfully.com

What is Mindfulness

Deb Kory: In this day and age a lot of people are throwing around the term mindfulness. Many therapists—particularly in the Bay Area—describe their approach as “mindfulness-based,” but I have a feeling that most people don’t actually know what that means. What exactly is mindfulness? What does it mean to be a mindfulness-based therapist?
Tara Brach: Mindfulness is a way of paying attention moment-to-moment to what’s happening within and around us without judgment.

Mindfulness is a way of paying attention moment-to-moment to what’s happening within and around us without judgment. So, said differently, when we attend to the moment-to-moment flow of experience, and recognize what’s happening…fully allowing it, not adding judgment or commentary, then we are cultivating a mindful awareness.

DK: So, it’s non-judgmental awareness of the present moment?
TB: That’s another way to say it, yes.
DK: How does that relate to being a mindfulness-based psychotherapist? What does that mean?
TB: It means that intrinsic to the psychotherapy is a valuing of cultivating that kind of attention, and an encouragement of the person you’re working with to cultivate it, and a use of it yourself. It can be sometimes formally woven into the therapy, but sometimes it’s just implicit.

Meditation and Psychotherapy

DK: Where does meditation come in? Is that a necessary part of mindfulness work?
TB: Meditation is the deliberate training of attention. So, when you do a mindfulness meditation, you are deliberately cultivating mindfulness by using strategies to enter the present moment and to let go of judgment and so on.
DK: So, it’s a way to help cultivate awareness of the present moment, and I would imagine that’s especially important for therapists. Does that mean that you actually do meditation in your sessions with people?
TB: Well, some people do, and some people don’t. I’m not in active clinical practice right now. I was, for several decades, seeing clients regularly and then turned to mostly writing and teaching and training therapists in how to weave mindfulness into their practice. So, I’m no longer seeing clients myself, but when I did see clients and when I work with people and do sessions that are related to meditation training—I would often, as part of a process of them getting in touch with what was going on inside them, invite them to pause and just simply use a period of time to quiet the mind, to just notice the changing flow of experience, or maybe to do a particular compassion practice. So, I would weave particular styles of meditation into a therapy session.
DK: Would you suggest that people do it in their day-to-day lives also?
TB: It very much depends on the client that you’re working with. For some people, talking about meditation, suggesting that they meditate, is a set-up for failure and shame. They’ll try to comply because they think, “Oh, Tara is this well known meditation teacher and this is what she’s into, so I should do it,” and so on; whereas it’s not a fit for them at that particular time.

Many therapists already, just by the nature of who they are, have a natural sense of coming into presence and a deep sensitivity to other people, but all of us get help by training.

So there were many people I would see where it would be much more of an implicit part of the process. I’d be encouraging attention to what was going on in the moment, encouraging them to just notice their experience without adding any story—all things that we would associate with meditation practice without saying, “Hey, we’re meditating.” What makes meditation meditation is that it’s an intentional process of paying attention on purpose to the present moment.

DK: And it doesn’t necessarily mean sitting in the lotus pose, right? It’s something that you can do in your daily life walking out in the world?
TB: Absolutely. Meditation is a training of attention that you can do in any posture, at any moment, doing anything that you’re doing on the planet. In fact, for us to have the fruits of meditation, we have to be able to take it out of a compartment or a particular context and have it just be, you know, here’s Deborah and Tara doing a Skype call. So, we’re not leaving meditation behind just because we’re in the midst of an activity.
DK: Thanks, that helps me relax a little bit!
TB: Yeah, it helps to name what we’re doing. I think psychotherapy and meditation are incredibly synergistic and they fill in for each other in some important domains. There are many things that come up when we’re meditating that we really actually don’t have the resilience or the focus to untangle, and a therapist can help us do that. The relationship itself, a trusting respectful relationship, creates a sense of safety that can enable us to unpack things that we might not be able to work on when we’re on our own, especially if there’s trauma.There are increasing numbers of people who are recognizing they have trauma in their bodies, and when they start to meditate and feel like they’re kind of coming close to that, they can get flooded, overwhelmed. In therapy it’s possible for people to establish safety and stability so that they can just begin to put their toe in the water and go back and forth between being with the therapist and touching into their resourcefulness and then dipping a little into the places in their body and their heart where they’re feeling this more traumatic wounding. That kind of a process, if we tried it on our own just in a meditation setting, could potentially re-traumatize us.

DK: So the therapist offers a safe container for the traumatic feelings.
TB: Yes, and the relationship that really enables a person to have the support in untangling. What meditation offers to therapy is a systematic way of training the attention. Where the therapist might help a person focus and stay focused on the present moment when encountering a painful issue, meditation training teaches us to do it on our own. It builds that muscle of being able to come back to this moment, even if it connects us with something we have habitually resisted.Meditation also trains us to, on our own, get the knack of offering ourselves compassion or forgiveness so that we can leave the therapy setting and continue in a kind of transformational way to be with the contents of our own psyche and wake up from limiting beliefs and the painful emotions.

DK: It seems at least as important for the therapist to have that ability to stay present, because there’s a transmission that happens. There is an energetic quality to what we do.
TB: Exactly right. Many therapists already, just by the nature of who they are, have a natural sense of coming into presence and a deep sensitivity to other people, but all of us get help by training. All of us.

The Alive Zone

DK: One of the things I was going to ask you was about how you differentiated your roles as psychotherapist and spiritual teacher, but you’ve said you actually are no longer in clinical practice. What led to that decision to leave that particular role and go more into teaching and writing?
TB: Well, I had done clinical practice for many years and, I think, the place where I felt most needed and most alive is in the process of teaching people how to wake up their hearts and minds, and with that I mean both the practices and the whole inquiry about what really serves freedom. That realm was much more alive for me. For many, many people—most of us I’d say—meditation and therapy are incredibly juicy. They weave together beautifully. So it wasn’t that I was thinking therapy wasn’t an alive zone—it was just that I had put my energies really into the teaching side of things, and I was writing and that took a lot of time.
DK: Aren’t there some areas of the profession that are a little bit deadening though? I’m just about to get licensed myself after an 8-year-long process, and I have been somewhat disheartened at times by the way the profession is organized—its restrictions, the whole 50-minute-hour, the billing and diagnosing, the legal and ethical structures that can at times seem very fear-based and a bit paranoid. I’m curious about what might have felt restricting to you.
TB: Well, the culture does not support the kind of processes of transformation that I’m most excited about, and they take time and immersion. I love retreat settings where people can really give themselves to a very deep attention. I like working with people when there is a longer period of time for people to be together and really have the inquiry and the experience, have the time to unfold. So, as you mentioned, with the slot of a 50-minute-hour, there’s a kind of rigidity that is necessary in some ways, but not so much to my liking.
DK: In my experience—and I live in Berkeley, CA, which is considered progressive and rather “woo woo”—spirituality and religion were not incorporated into our professional training. We aren’t taught to value it except in a kind of multicultural, “let’s be tolerant of other points of view” kind of way. There’s an emphasis on scientific methodology, assessment, empirically validated research, etc., that feels very split off from what you’re talking about. I wonder if that was your experience at all?
TB: Well, what’s alive about therapy is the therapeutic relationship and, like any other two humans connecting, nothing can really flatten that. If you know you want to show up and be with somebody and really know that you’re there to see the goodness in the other person, you’re there to help recognize the patterns that are getting in the way, you’re there to hold a container moving through difficult material—that all is beautiful, and that can happen regardless of the structure around it.That said, I find that I do that more effectively with people in sessions that are more focused on how to bring meditation to difficult experiences. My interest is not so much to do with coping strategies or too much emphasis on the storyline;

I’m more interested in our potential to realize the full truth of who we are beyond the story of a separate self. Most therapy is not geared in that direction. People that end up working with me, or working individually with me doing what I might call spiritual counseling, are kind of a self-selected group of people that are interested in a more transpersonal kind of work–not in any way to ignore the issues of the personal self, but to have the personal be a portal to the universal, and an expression of our awake heart and awareness.

DK: Where did you go to get your degree in clinical psychology?
TB: I did my undergraduate work at Clarke University, and I did my graduate degree at Fielding Institute, which is out on the West Coast in Santa Barbara.
DK: What was your plan at the time?
TB: Well, even then—I had lived in an ashram for 10 years—I was approaching psychotherapy in a very holistic way. I was doing yoga, teaching yoga, and weaving yoga and meditation into any work I did with people. So I’ve always been blending East and West together, right from the get-go.My plan was to keep doing this, to be able to have a degree so I could afford to have this as a profession. I have a fascination with the psyche. I mean, I’m totally interested in how we create limiting realities about ourselves, and our capacity to see beyond the veil to the vastness and mystery of who we are. So my plan was just to keep on weaving these worlds together in whatever way would be most alive.

The Trance of Bad Personhood

DK: I read somewhere that you wrote your dissertation on eating disorders?
TB: Yeah. I had struggled with an eating disorder for a good number of years—probably 5 years—and meditation was really helpful; basically, it taught me how to pause. There’s a wonderful saying that between the stimulus and the response there is a space, and in that space is our power and our freedom. That’s Viktor Frankl. So the practice of meditation taught me how to pause and open mindfully to the space so that there’d be a craving or fear, but there would be some space between that and action.It also taught me a lot about self-compassion. I found that addiction is fueled by blaming ourselves. In Buddhism, they call it “the second arrow.”

The first arrow is the craving or the fear or whatever; the second arrow is, “I’m a bad person for having these feelings or doing these behaviors.” The “bad person” arrow actually locks us into the very behaviors that are causing suffering. So, in both Radical Acceptance and True Refuge, I emphasize a lot about how to wake up from that trance of bad personhood.

DK: One of the things I like about your work is that it’s very integrative. I get a sense that you’re really open to cognitive science, to philosophy, to various wisdom traditions, to 12-step programs—essentially to whatever seems to work for people. As someone who has benefited a great deal from the twelve-step model, I’m also well aware that it doesn’t work for everyone and that we have to have a big tool box available to help clients—particularly those struggling with powerful addictions. What’s your approach when working with addicts?
TB: Well, my inquiry is always, what have you been exploring and what helps? Humans are really resourceful, so I always try to find out what works for you. Of course, there are so many different approaches. I did my dissertation on binge-eating and meditation practice, but it became very clear to me that without having a relational component, without having a group and people to support you, nothing would hold. Whether it’s a 12-step group or in the Buddhist communities we have the kalyana mitta groups, or spiritual friends groups—the great gift is that we really get that suffering is universal, that we’re not alone in it, that it’s not so personal, that there’s hope, there are ways that we wake up out of it, and that we’re there for each other. We’re kind of in it together.
If there’s any medicine in the whole world, it’s that sense of belonging, of connection with others.I think that on the spiritual path, meditation—learning to be here in the present moment—is critical; but equally essential and interdependent is the domain of sangha, or community. We need to discover who we are in relationship with others. Whether it is addiction or any other form of suffering, a mindful relationship with our inner life and with each other is what de-conditions the contracted beliefs, feelings and resultant behaviors.

What gives hope is described in recent science as neuroplasticity. The patterns in our mind that sustain suffering can be transformed. And how we pay attention is the key agent. A kind and lucid attention untangles the tangles!

Will This Serve?

DK: In your work, you really make a concerted effort to share your own fallibility, and I think that for psychotherapists that’s a really tough one. I feel quite committed to that in my own practice, and yet I notice that I’m often pulled to frame things as, “long, long ago, when I was sick,” you know? But I’m not that old, so it couldn’t have been that long ago.
TB: Right…as long as there’s a 10-year gap between now and when I was really confused…
DK: Exactly. So it’s something I really try to work on, because I know in my own experiences as a client in therapy and in supervision, that I feel safest and most connected when people are willing to share with me not just that they were screwed up in the past, but that they’re still screwed up, because we all are.
TB: Yeah, the vulnerability, the fear, the shame—it all continues to rise throughout life. I’ve made that kind of vulnerable sharing a deliberate practice for a few reasons. One is, it’s the truth. I mean, there’s no way there’s not going to be projection when you’re a teacher or a therapist, but I really feel like mindfully sharing about our personal foibles serves. I regularly get caught up in self-centered thoughts, impatience, irritability, anxiety, the whole neurotic range. And…the truth is that I’ve been blessed to have increasing freedom, you know? That pain and difficulty and stuff keeps arising, but so does a mindful, compassionate way of relating to what’s happening. The result is there’s less and less of a sense that it’s happening to a self or caused by a self. I know how valuable it is for people to see that as a therapist or as a teacher that you have a certain amount of happiness or freedom in your life and that you’re still working on things. It gives hope.
DK: Yes, it’s a fine balance.
TB: It’s a fine balance. I think the inquiry is always, will this serve? We’re not doing it to unload; we’re not doing it to be a certain kind of person. It’s just, will this serve? But, I have found for myself that leaning in that direction is usually beneficial.

What We Talk About When We Talk About Love

DK: You also talk a lot about love. I felt very clearly that I came into the profession in order to practice love—to practice it and to practice it, learn about it. But in my training, I literally never heard the word uttered. I made a point to bring it into discussions at school and at training sites, but in my experience it was a lot easier for people to talk about hate—“hate in the counter-transference” and love as just “positive countertransference.” Obviously there have been terrible abuses of power by therapists in the name of love, but it seems like the response has been an over-correction, and has left us without a proper vocabulary for what we are actually doing.
TB: Well, as you were speaking, I was thinking that it’s beginning to change. That’s the good news, Deborah. I mean, there is so much research now on self-compassion and compassion for others. There are universities like Stanford, which has a whole institute—The Center for Compassion and Altruism Research and Education (CCARE)—dedicated to compassion studies. Compassion is love when we experience another person’s vulnerability or suffering. Love, in terms of loving-kindness, is described as love when we see the goodness in what we cherish. Gratitude and appreciation and love and beauty are all words and places, domains of attention that are actually becoming more common in the psychotherapeutic community.And I feel like it’s really important that we consciously take this one on. For instance, I have made a point of talking about prayer and talking about calling on the beloved and calling on loving presence when I feel very, very separate…really reaching out to that which feels like a source of loving presence and then discovering it wasn’t outside of me, but I first have to go through the motions. So it starts with a dualistic sense, and then it ends up revealing unity. I’ve made a point of talking about that when I’m doing keynotes at professional conferences, because I really want there to be an increasing acceptance and comfort with the language of prayer.

How could it be that we all have these longings? I mean, every one of us longs to belong. Every one of us longs for refuge. We long for feeling embraced. We long to feel bathed in love. We long to touch peace.

That’s prayer. That longing, when conscious and expressed, is the fullness of prayer, and for us to acknowledge the poignancy of it and invite people to recognize it and have it arise from a depth of sincerity, actually is a very powerful part of healing. Prayer is a powerful part of healing. It helps us step out of a small and separate ego kind of sensibility, and recognize a larger belonging.

So I feel like we’re at a very juicy kind of era in psychotherapy where more and more of the profession is opening itself to intentional training and training in self-compassion. It has definitely opened its doors to that. It’s opened the doors to mindfulness in a big way, and when you open those doors, people become more embodied and there’s more creativity, more possibility.

The Squeeze

DK: The title of your new book is True Refuge, and it speaks to, I think, both the longing and the possibility for refuge inside of ourselves that we create in relation to others, as part of the human community. What’s the relationship between this new book and your first book, Radical Acceptance?
TB: Well, I wrote Radical Acceptance because I was aware in my own life and with most everybody I connected with that probably the deepest, most-pervasive suffering is that feeling that something is wrong with me.I called it the “trance of unworthiness,” because most people I know get it that they judge themselves too much and they’re down on themselves, but are not aware of how many moments of their life that assumption of falling short is in some way constricting their behaviors and stopping them from being spontaneous. You know, it could be that here we are doing this interview, but there’s some nagging sense of, “Oh, I should be doing this better,” and how that in some way blocks the heart from being as open and tender. It’s just, we’re not aware of how many parts of our life are squeezed by a sense of deficiency.

I’ve found that until we are aware of that squeeze, we’re caught in the trance. So I wrote the book because I wanted to say, “hey guys, we’re all going around feeling bad about ourselves,” and explore how practices of freedom—cultivating a mindful awareness, cultivating compassion, cultivating a forgiving heart, learning to turn towards awareness itself to begin to recognize its formless presence that’s always here—help to dissolve the trance and reveal who we are. This vastness and this mystery is looking through our eyes right now, even though we’re just looking at a computer screen—there’s this sentience and it’s so cool. So the purpose of Radical Acceptance was to very much draw attention to that trance.

DK: And what was the purpose of writing True Refuge?
TB: In True Refuge, I enlarged the scope because in addition to unworthiness, our basic trance of separateness gives us a very profound sense of uncertainty and loss. I think it becomes more vivid as we age that, “okay, these bodies go, everyone we love goes, these minds go.” Right now, for example, I’m watching my mother lose her memory as dementia is setting in. Just watching that happen is painful and sad.But what directly motivated me to write True Refuge was a period of about 8 years of a steady decline in physical health. There was a time that I had no idea whether I’d regain any of my capacities I had lost. I have a genetic disease that affects my connective tissue, so I had to give up running, give up biking, and give up a lot of the recreational activities I most love. I remember at one point being completely filled with grief at the loss and sensing this deep longing, a very poignant longing, to love no matter what. Really I just wanted to find some refuge, some sense of peace and okay-ness, openheartedness, in the midst of whatever, including dying. That feels important to me. So True Refuge was approaching a broader domain: How do we find an inner sanctuary of peace in the midst of all the different ways that life comes and goes? How do we come home to that?

DK: When the pain of life brings you to your knees…
TB: Exactly. I remember being very struck by William James, who wrote that “all religions start with the cry, ‘help.’” Somehow deep in our psyches there is always some part of us that’s going, “Okay, how am I going to deal with this life? How am I going to deal with what’s around the corner?” What happens for most people—and this is kind of the way I organized True Refuge—is that we develop strategies to try to navigate life that often don’t work. I call these false refuges. This is in all the wisdom traditions. We know that the grasping and the resisting and the overeating and the over-consuming and the distracting ourselves and the proving ourselves and the overachieving… just don’t create that sanctuary of safety and peace and well-being. It just doesn’t work.So in the book I talk about our false refuges and then explore what are really three archetypal gateways to homecoming. You can find them in all the different world religions including Christianity, Judaism, Hinduism, and it’s most clear for me through Buddhism. These three gateways are: truth (arising from mindfulness of the present moment), love and awareness. In Buddhism these are ordered differently and called Buddha (awareness), Dharma (truth) and sangha (love).

So the architecture of the book is based on that, and I used a lot of stories—my own stories, and other people’s stories—to address the pain of feeling deficient, but a lot of other struggles also.

No Mud, No Lotus

DK: The parts of True Refuge that were most moving to me were the descriptions of your struggle with your disease, because there is just no getting around how painful and difficult that must be. You really share your cry for help and the fact that you’ve been able to make some peace with it is both awe-inspiring and hopeful, since all of us, as you say, will face our own physical demise. But it does seem like living with chronic pain that severely limits your mobility is one of the deeper sorts of spiritual challenges that we face. Do you feel grateful for what it’s taught you?
TB: Yeah, I do. You know, I’ve heard many, many people say from the cancer diagnosis or the heart wrenching divorce or whatever it is that they wouldn’t trade it for the world. I feel the same way. “No mud, no lotus,” as the Buddhist saying goes. We wake up through the circumstances of our life, and the gift is that when it gets really hard you have to dig very, very deep into your being to find some sense of where love and peace and freedom are. Our experience of inner freedom is not reliable if it is hitched to life being a certain way. If I’m dependent on my body being able to run to feel good, I’m going to be in trouble. I’m actually better than I was before physically, but there were times when I couldn’t leave my house. I couldn’t do much of anything, and there was a growing capacity to come into a beingness and an openheartedness that allowed me to feel just as alive and present and happy as if I could have been romping around outside and running through the hills.I think of that as freedom. I think of freedom as our capacity to be openhearted and awake and have some spaciousness in the midst of whatever is unfolding. The gift of it is that we start to trust who we really are. There’s a sense of trust in the awareness that is here, the tenderness of our heart, the wakeful openness of our being. This becomes increasingly familiar, rather than the identify of a self-character that is able to do this and doesn’t do that and is great or terrible at such and such. We are living from a sense of what we are that can’t be grasped by words or concepts, but can be realized and wholeheartedly lived.

So, that is the fruit of True Refuge—that our true refuge is our true nature. Our true refuge is our true nature. It’s none other. The three gateways are just different energetic expressions of true nature.

DK: How did getting a degenerative chronic pain disease change your work with people?
TB: Before this happened, I was pretty much an athletic jock type that had some vanity around my fitness. And I’ve emerged much more humble, and also much more compassionate towards others. I know what loss is. There’s something I sometimes call the “community of loss,” where each of us has lost something deeply important—whether we’ve lost a partner, or lost a job, or lost our health, our home. I just got back from teaching a weekend at Kripalu Retreat Center in Western Massachusetts, and a number of people there had been hit by hurricane Sandy. One woman was telling me what it was like to have her home totally demolished. The community of loss. The more awake we are to realizing we’re part of it, the more we’re holding hands with others, really the more compassionate a world we have.

Awakening to the World’s Suffering

DK: Speaking of which, I know that political activism has been a big part of your work. You bring issues of social justice into your teachings. One of the things that comes to mind is a talk that you gave about racism within your spiritual community—not overt racism, but a more subtle but nonetheless insidious kind of racism that we find just about everywhere in our culture. It was painful for you to be made aware of it and you shared it as a way to bring awareness into your community. I have also appreciated the way that you struggle with modern politics in your work—trying to remain open-hearted but still having a coherent political voice. How important is it in the work that you’re doing? How has that changed over time?
TB: Well, it only becomes increasingly clear to me that the awakening of our heart and mind means awakening to our belonging to the world and that there’s not a spiritual path that can be extricated or isolated from that belonging. This means that not speaking is in fact making a statement. Our thoughts, our speech, and our actions in terms of the broader community completely matter. They matter. They express our awakeness and then they affect what happens in the world.It feels essential that those who value being spiritually awake recognize that that includes being engaged consciously in our larger world, wherever it is that we feel particularly drawn.

We have to recognize that our earth is dying, that denial is the biggest danger in the world for our planet. We have to be willing to be touched by the suffering of the earth, the air, the creatures that are going extinct, to be touched by the pain that people experience when they’ve been discriminated against and shamed and isolated in different ways, marginalized in our culture—that’s part of being awake and open in the world.

DK: What kind of social or political activism are you currently involved in?
TB: I try to respond to what goes on in our own community, and our community is involved with a number of domains. There are some green activities that are, I think, pretty cool. We’re fumbling around on the diversity front, sometimes in a painful way. Like most communities that have a majority of white people, the big question is how to wake up and be more responsive to the racism that is just naturally there. It’s just part of the culture. I’m also very much supporting getting the mindfulness curriculum and mindfulness in schools around here. And we have a lot of activity around teaching in prisons. So the best I can do as a leader in the Washington area is to support those kinds of activities. As you can tell, I do feel passionately that it’s not meant to be just on the cushion.
DK: So it’s not separate at all—any of it.
TB: Nothing is separate. We belong to this world, and it’s part of the way we’re trying to bring compassion to these bodies and hearts and minds. We need to bring compassion to those that are suffering from an unjust society, and we need to bring compassion to the earth.
DK: Is there a place for anger in this struggle?
TB: Absolutely. We all are wired to have a range of emotions that are just life energies, and to not regard them as wrong or unspiritual is really important, to respect them. They all have an intelligent message, we wouldn’t have been rigged with them if they didn’t. Our work is to learn how to be in relationship with them in a way where we can listen, where we can embrace the life energy and not get identified with the storyline they may elicit.What happens with anger is we can get fixated on, “You did something wrong to me.” When this happens, the practice is, instead of believing the story, to instead see if we can honor the energy and feel what’s going on inside us.

This usually involves bringing real kindness and mindfulness to the feeling of being hurt, the feeling of vulnerability, the feeling of fear, but not buy into the storyline of, “you’re bad and I need to get you back.” Because if we can pay attention to the message of anger—“there’s some threat, I need to take care of it”—and feel where we feel threatened inside, we’ll reconnect with the natural intelligence and compassion of our own heart-minds, and then respond with more wisdom. So go ahead and create boundaries, go ahead and speak your truth, but from a place of presence and intelligence and kindness, not from a burst of reactivity.

DK: Which takes a lot of practice over a lot of time.
TB: Huge practice, because we’re basically moving against our more primal reflexive reactivity, and learning to cultivate a response from the more recently evolved part of our brain. Our conditioning is to have an impulse arise and act out of it, so as to release the tension and feel soothed. It’s coming back to that quote from Victor Frankl. This is saying, “Pause….First come home to the experience that is here and pay attention.” That is the heart of the training, and it takes practice. In True Refuge, I use the acronym RAIN, and I’ve added some different dimensions than are usually emphasized in much of the Buddhist teachings. It’s a really simple and powerful handle to, instead of react, come into a relationship with what’s going on in a much more wise and balanced way.

RAIN

DK: Can you briefly go through what you mean by RAIN?
TB: Sure. RAIN is an acronym to support us in cultivating mindful awareness, and the basic elements of mindfulness are to recognize what’s going on in the moment and to allow it. That’s the core of RAIN: to Recognize and Allow. What happens often is we’ve got a tangle going on—let’s say it’s anger. We’ve got a storyline of the anger, and we’ve got the feelings, and we’re wanting to do something, and it’s all jumbled up. What we’re doing with RAIN is saying, “Okay, I Recognize anger is here and I Allow it.”But it’s still feeling very sticky and very demanding of attention. So we deepen attention with the “I”—Investigate. But it has to be a compassionate investigation because if we investigate as a detached observer, or we investigate and there is some judgment and aversion, then the more vulnerable places within us will not reveal themselves to the investigation. For investigation to unfold to truth, we need to bring real compassion. I sometimes think of it as the rain of compassion or self-compassion, because we really need that quality.

DK: Yeah, it’s so easy to bring a subtle kind of judgment into that kind of investigation. Like, “why do I always trip out on this?” or “here’s my damn depression again.”
TB: If you think of a child who’s upset and you want to find out what’s going on, if there’s not a sense of caring, if you just ask questions, it’s not going to work. So we begin to investigate within ourselves, ”Okay, anger. What am I believing right now?” If we ask that question, it can easily veer off into concepts. But the more we bring a gentle presence, a caring presence, a clear presence to the actual experience of what’s going on, the more there is a shift in a sense of our identity. If you’re very, very present with the anger, you’re no longer the angry person believing in the story; you’re the presence that’s present. You are the awareness that’s noticing. That shift in identity is the whole key to the transformation that Buddha talked about in awakening to freedom. And the body is the major domain of investigating—the throat, the chest, and the belly. Just really arrive and sense, “how is this experience playing out through this body?”After the “I” of RAIN gives us that presence, the “N” is “Non-identification.” Another way to say it is the “N” is “Natural awareness.” We are re-embodying or reestablished in our natural, vast, compassionate awareness.

DK: So, it’s really the opposite of dissociating?
TB: Exactly right. Neither dissociating nor getting possessed. When we’re identified with an experience, either it grabs us and we become the angry person, or we disassociate and become kind of numb and cerebral. Either one of those is, in a way, moving away from the reality of the present moment. RAIN is the way to come into the present moment. We can bring it into our relationships so that when there is conflict with another person, or with another country, or with some “other” that we consider kind of unreal or bad, if we’re able to first bring RAIN inwardly and just sense what we’re feeling and be with that presence and open up our sense of identity, we can then look at another person with the possibility of inquiry. What is really going on here? What is the unmet need? What is your vulnerability? What are the fears or hurts that might have led you to that behavior? We get to see through the eyes of wisdom. RAIN, or more broadly speaking this capacity for mindful awareness, is actually the grounds of compassion for ourselves and each other. It gives us a chance to really sense who we are beyond the mask.
DK: Thanks so much. It has been a joy to talk with you.
TB: Thank you.

Philip Guerin on Bowenian Family Therapy

Posted on by rezendevknowfully.com

The Family of Origin

Ruth Wetherford: So, Dr. Phil Guerin, give us your background. What is your current situation? How have you gotten into family of origin work?
Philip Guerin: Well, my family of origin work goes way back. I’ve been in practice now about 45 years. I was a medical student at Georgetown, and the program was primarily a psychoanalytic program, so I spent my medical school time using psychoanalytic-psychodynamic models, transference models. I didn’t meet Murray Bowen until I was a resident, and he was my introduction to family of origin work. His whole model is mostly family of origin work, so that was a good introduction.By the time I met him I was already somewhat impatient with what in those days was called “the working through process” in the transferential model. I myself had been in therapy as part of the training and was somewhat dubious about how much the working through process really took place. In my own analytic therapy, I didn’t see much attention being given to it. And in working with patients, I found that things tended to drop off and never quite got through the working through process. And as a result, people often had dredged up a lot of negative affect and feelings about their important objects during their individual therapy and were then left with no place to work that through, other than to hold on to negative precepts about those people which resulted in exaggerated distance and a lot of blaming of those people for their own neurotic hang ups.

RW: That is a common complaint of people in therapy as well as of therapists. We do all this digging, we excavate the woolly mammoth—now what do we do?
PG: Exactly. So I found that trying to find a way that one could put some structure on the family of origin, and then define the field that those people occupied, look at the key conflicted processes, the important triangles, the cutoffs—all those things that we know about from our family system training—and really actually work through some of that process with somebody who knew the terrain. I was fortunate enough to have a guy through my terrain in the person of Bowen. And I did some significant relatively long-term work with him on my own family of origin. So that’s how I got into it. And I have found that it has been a real help in my own personal life. And, on the other hand, difficult to sell to people in terms of being relevant to their everyday lives.So I had to learn to not sell it, but to integrate it somehow around the symptoms of the relationship conflicts that came up so that people could see and learn its relevance. I don’t know what you think, Ruth, but I think in our current culture there’s even less investment in family of origin as an important and valuable asset in people’s lives.

There’s so much fragmentation of families, in particular the multi-generational families, that I think people, now that I’ve been in the business long enough, they kind of self-select in terms of coming to see me. So I either end up with somebody that’s coming in with the family of origin problem or somebody that isn’t awfully interested in it and we end up focusing on their symptoms and maybe working the family of origin in as part of that process.

RW: What are some of the basic concepts that you really like about this approach that help you organize your observations and your moves as a therapist?
PG: I think that the two things that are key, in terms of helping people with this clinically, is that much of the developmental and/or situational stress in our lives emanates from family of origin stuff. You know, you haven’t seen your mother in 15 years and she suddenly has a terminal illness. Something happens to your brother and he loses his job—there’s any number of those kinds of situational things. And the developmental things are obvious—when somebody gets married they are supposed to shift their loyalty from their parents to their loved one as their primary object of choice, but that’s actually very difficult to do.And what that brings up is a triangle right out of nowhere, which you also had when you were a little kid—just born into a family and you started out somewhere caught up between your mother and father. So those kinds of things and contextualizing them into the larger family I find really helpful as a road map to develop people’s treatment plans.

RW: So there’s the concept of the triangle and the other concept is…?
PG: Well, I think the triangle is obviously very central. But when I see a clinical situation that comes to me I make an assumption that it’s based on an increase in stress in the people’s lives.
RW: Stress is a key concept.
PG: That manifests itself in an exacerbation of relationship conflict or some physical symptoms that’s returned or depression or anxiety. And those things are best understood if you can put them into context of a family—the family of their spouse and kids or the family they came from.

Triangles

RW: In your book, Working with Relationship Triangles, which you wrote with Fogarty, Fay and Kautto, you go into great detail about the nature, structure, and process of triangles. It’s a working manual about how to apply your theories and ideas into action. One of the things that you say in the book is that a triangle is not a threesome. A threesome is not a triangle. What is the distinction you’re making here?
PG: I think that’s a distinction that Fogarty makes and it’s something he puts very high on the list of things that people have to be able to do. What it means is that a threesome is three individual relationships in which there isn’t a lot of reactivity among the folks. There’s nobody on the outside looking in. There isn’t an intense conflict in a dyad that the third person is getting distance from. He used to talk about it as an equilateral triangle in which there was calm in each of the three relationships. And if there’s calm, then all kinds of good things can happen.But triangles are very pervasive. You don’t have to put three people together very long before they fall into triangles.

RW: So you’re saying that the term “triangle” itself implies not just that each of the dyads that you’re in with two other people is affected by their relationship with each other, but that it has become dysfunctional in some way.
PG: Yeah, and that can be by excluding one person. The concept of triangle has built into it that it’s dysfunctional and inhibits people in the system from finding ways to uncover and deal with their difficulties.

Differentiation of Self

RW: How much do you use and think about the concept of “differentiation of self”?
PG: Differentiation of self is one of those things that obviously was one of Bowen’s original concepts. And he stuck with that through his whole career and believed it to be of primary importance because he believed that if individuals could increase their level of differentiation—which in concrete clinical terms means that they are less emotionally reactive and can think their way through their problematic relationship road blocks—then everything would fall into place. Symptoms would go away. Functionality in relationships would improve. I find that it’s abstract enough that it’s difficult to stay focused on that.And so one of the things that I developed was the whole idea that we are mostly left with the level of differentiation that we’re born with. We can make some progress on it over time, but mostly by finding ways of working within that to improve our ongoing level of functioning. It’s kind of like functioning in spite of your level of differentiation.
RW: When we add to that definition the internal ability to feel and think what is true for oneself’ separate from the pressures of your closest social environment and separate from coercion, that eliminates many people who are dependent for their survival, their food, etc. on the dominating power of others.But for that subset who can have the freedom to think and feel what might be true for them, and in so doing reduce the emotionality that you were just talking about, that strikes me as something that one can do, slowly and incrementally throughout one’s life if one knows how liberating and freeing it can be. In fact, the first time I was reading about differentiation of self with Bowen, I thought, “What a light bulb for humanity because it rescues us from the prevailing power dynamics in most families—that the rights and needs of the many are meant to be sacrificed for the good of the few.” And this concept that we’re equally entitled to our own subjective experiences, that seemed so new.

PG: I think you put it very succinctly and I think you put it in a way that is very useful for folks. I have been struck over the years by the power of emotional forces and how easily they can overwhelm even the best of strugglers who are trying to get to a differentiated perspective.
RW: Yes, that’s so true.
PG: It’s out of respect for the power of emotionality that I put some qualifiers on differentiation as the central process of family of origin work. I think it’s also one of those things that people hide behind a lot; they talk about how much they’re differentiating themselves but, frankly, I don’t see it, right?From the work I’ve done in my own family, I’ve found how easy it is to kid yourself for five years that you are rolling along increasing your differentiation when it finally hits you over the head that you haven’t been. You’ve been playing the side game, but it doesn’t have much to do with differentiation.

RW: Right. Just following up on what you said about how easy it is to think we’re differentiating, to me the cue of the power of that emotional force is anxiety. I’m getting ready to go visit my family—why am I so anxious? And it’s so helpful to think about who are the two people with whom I feel most anxious and why, and then go into those thoughts. I think you’d call it an application or a “thought experiment.” What kinds of applications have you used that that might help people understand how to go about thinking about this more deeply?
PG: Well, I like to use the concrete behaviors in people’s relationships and develop them into experiments with some kind of modification of a behavioral pattern. And while you’re doing that, pay attention to what’s going on internally. And if you start to get anxious, that’s important information. And pay attention to the reactive behaviors and the important other people in your family. And sometimes you’ll find that the reactivity that they have shuts down your ability to even think.
RW: So you ask for observations.
PG: I do.
RW: And you help people identify what in particular they’re going to be looking for to observe?
PG: You mean like if they’re making a trip home?
RW: Yeah, or a phone call, email, text or any contact with the person who is the trigger for anxiety.
PG: Yeah, or outside of the therapy session as well. Because you often end up working with one family member in a lot of this.
RW: Yes. And you do make a point that the work is best with those people who are open to the approach of taking control of their own calming and who understand that they can try to change their participation and the repeating sequences of interaction. Have you asked people to identify the repeating difficult sequence of interaction that makes their anxiety shoot up?
PG: Well, if they’re going to be going to a family of origin visit, I would be probably more generic than that and just have them go and really try to keep their own anxiety in check and observe what they see around them. And then bring what they observe back and we’ll put it together and talk about it and maybe design something that goes on over time—combination letters, telephone, other visits, etc.And I think that that does help people get a sense of mastery and a sense that they don’t have to be so anxious and frightened about moving into the relationship and changing their responses to difficult interactions.

Techniques

RW: You said in your Bowenian family therapy video that Bowen sneered at the word “technique.” I wonder do you have techniques?
PG: I think that in Working with Triangles and in some of the stuff that I’ve done in the form of chapters in other people’s books, I spell out a number of techniques that I think are important to the method. And I think there’re seven of them. I probably couldn’t even come up with more than three of them now. But I certainly have techniques that I think are just applications of observations and theories about the way relationships work.
RW: Donald S. Williamson, who wrote The Intimacy Paradox, and Betty Carter and others do have explicit sequences of moves to help people identify the toxic triangle and calm themselves, notice the repeating patterns, identify their own reactions to things that are said, and then develop a self-stated goal for their own change in behavior. Then they take a step, however small and metaphoric, toward that goal and report back on how it went. In this way they differentiate themselves gradually and hopefully humorously.When people do this there’s an enormous amount of emotion that’s released which, according to those family therapists, needs to be expressed outside the family—the hurt, the anger, the intensity—so that through the release of pent-up emotion there’s less pressure to have it come out in interactions. How much of that emotional release have you experienced using such a cognitively based therapy?
PG: Well, I think that in all those paradoxical ways if you ask people to put their cognitive apparatus to work and observe and experiment with the relationship process they’re a part of, the emotion surfaces in very dramatic ways. And if it’s going to be external, I hope it’s in a context with somebody who is a coach or a therapist because otherwise, you know—I was just watching a movie over the weekend which was a remake of a 1939 movie called Women, in which part of what was going on was the group of women that surrounded Meg Ryan when she found out her husband had an affair. And they had more opinions about what she should do and ways to deal with her upset. And so that can be somewhat questionable in terms of its helpfulness, but I think if it gets spilled to your coach or your therapist, it can be very beneficial. You somehow neutralize the negative power and then go back into the relationship that is the source of it and get it talked out.
RW: Yes.
PG: That would be the best outcome. But I still think that the emotional vulnerability in each of us that triggers us to respond in an emotional way is very profound. And all the designs that Betty or Donald and myself come up with are ways of helping with this, helping the moment, helping the month—but over a long-term process of life it’s very easy to get pulled back in on an emotional basis and to be unaware of it.And so it becomes kind of a lifetime work. It’s very different than being in therapy for life, you know. I think that the difference is that therapy ties you to the individual, who is the therapist, and that the process of working it through is in that relationship. There’s nothing wrong with that. It works. But if it doesn’t get back into the natural relationships of your system, it’s going to be limited in the impact of that.

RW: Yes. You make the point in the book that when the therapy progress seems to be bogged down it’s useful to look for invisible triangles that may be holding the person’s behavior in a stuck place. And you mention that sometimes it can be the individual therapist or the couple therapist. So you’re alluding to the fact that we therapists ourselves have our own levels of differentiation and sometimes we tend to side with the client or patient against the people they’re complaining about. And what a mistake that is in that the therapist needs to work toward his or her own differentiation. Say more about that.
PG: Well, I think if you don’t develop an ability to empathize with your individual patient about what they’re struggling with and to hear them out and to validate them that the struggle is real and there’s justification for their feelings, then you’re not going to have too many patients for very long.That’s the first phase. And the second phase is, well, now that you know those feelings are natural and that maybe 90% of the folks on the planet would have them, well, how are you going to put them into a context that helps you develop a way to go work them through with that person? We therapists have to watch for that very fine line between being supportive and validating and just providing no real motivation to go do something about it.

RW: That’s right. If I see your point of view and validate your feelings, that does not mean I agree the others also have a point of view and that to do nothing about it. It doesn’t mean you can’t change your own reaction to it.
PG: It also doesn’t mean that part of your response doesn’t have its own negative set in it, you know? That’s a big part of the problem actually.
RW: Yes. You mentioned that this thinking leads you to ask questions that help the person see how their own interaction is negatively influencing the others and that we think of ourselves as innocently going along reacting to others, but we forget that they’re reacting to us. Say more about that.
PG: Well, it’s like the whole concept of constructive criticism. How many people do you know who are good at accepting constructive criticism?So I think an awareness of yourself and the toxic parts of you and how you trigger people into their own stuff is essential as a therapist,

An awareness of yourself and the toxic parts of you and how you trigger people into their own stuff is essential as a therapist.

The Invention of Genograms

RW: You coined the term genogram, is that right?
PG: Well, there’s a rumor to that effect, yes.
RW: Well, talk about the genogram and how useful that’s been to you.
PG: Bowen started using what he called “the family diagram.” And if you look at his writings and you watch his speeches, he never converted that over to genogram. Until the day he died, he talked about the family diagram. When I had left Georgetown and was at Einstein teaching the residents and fellows and medical students and the like, I did a lot of what you were talking about Don Williamson doing. I had what we called “TOF groups”—therapists’ own family groups—which was a practical way of trying to get people to learn the theory and the idea of the impact of the people in your family on your emotional functioning. And part of it was for people to, in seminar style, put their genogram up on a board, either a blackboard or an easel pad. And it just seemed to me that we were also teaching about generational repeats all the time.We were talking about intergenerational triangles and it was impressive how much the issues and the relationship patterns repeated themselves generation to generation. So I just thought people might relate to this and the notion of a genogram might stick in their head. It kind of gives you a structure with the membership of your system and the major issues in your system and the cutoffs and where they are and what drove them.

I think it’s been very helpful to people over the years and it’s probably one of the techniques or structures that people from other therapy approaches use.

RW: So after you create a genogram with people—whether you’re working with one person or a couple or a family—it helps you to understand the different forces that hold the system in place.
PG: Yes.

Functional and Dysfunctional Attachment

RW: In Working with Relationship Triangles, you say, “Quite apart from how people feel about the closeness or distance between themselves and others, we should make another distinction between kinds of closeness and distance. Closeness can be a kind of functional attachment. This allows people in a relationship to preserve their boundaries and their autonomy in thinking, feeling and action while they remain connected in a personal way to each other. Alternatively, closeness can be reactive and driven by anxiety, a kind of dependent clinging or anxious attachment that says implicitly or explicitly, ‘Please don’t leave me. I’ll do anything to keep you. If you leave, something terrible will happen.’ Similarly, distance can be a deliberate and planned exercise to deal appropriately with a developmental or relationship problem” (page 59).I quote this because it jumped out at me as very consistent with what a decade and a half later is the very important focus on attachment and the patterns of attachment—secure versus anxious and avoidant. Because you’re making the point, I think, that once we excavate what the core issue is—and it will often emanate from the marriage that then creates the nuclear family—the dynamic has to do with the tension around closeness and distance, in being able to get access to a feeling of connection or “are you there for me?” Functional attachment, anxious attachment, those are precursors to this new attachment conversation that’s going on. When you work with people, how do you focus on that issue, that struggle in them to find a happy, close enough, but not engulfing, far-enough-away-without-abandoning equilibrium?

PG: That’s a very good question. And I think if you realize that most attachments that people have with one another is of the anxious attachment variety that gets called love—as opposed to the kind of functional attachment where you add to that an ability to be open about your feelings for the other person. That’s different. And that is the root towards the kind of intimacy that all of us are looking for. I was thinking while I was listening to you read that section, “Yeah, that’s pretty good. I agree with that.”You were talking about techniques before—one of the techniques becomes the use of the process question: “Do you think that the importance of being connected to your husband comes from a need for a kind of closeness that will benefit you both in your ability to be intimate with one another and to function as individuals and as a dyad? Or do you think it’s kind of a clingy attempt to hide out behind him or in the relationship itself?” They’ll say, “Will you repeat that?”

I think that you take that notion and you try to get people to think about it. And you try to get people to think about it by asking some fairly brief—a lot briefer than that last question came out—questions to focus them on how much of their attachment is being driven by their anxiety, being driven by a fear of a loss of the other, being driven by a way of toning down what they’re experiencing as criticism. I think that can be very helpful to people.

Each of us has a different allergy in this regard. I mean, some people just have an emotional allergy to somebody who is clingy and wants to have their arm around them all the time and wants to exchange intimacies. Other people have an allergy to too much distance and too much avoidance and an inability to talk about the personal in the relationship itself. And how much of that is testosterone versus estrogen driven or whatever? I don’t think we know.

RW: No.
PG: But it remains something that’s consistent over the decades that that is a part of the problem and also can be a part of what feels good in a relationship. We used to have arguments at Einstein family study section where we’d talk about, “I don’t care if it is emotional fusion; it feels too good to let go of it!”RW: How have you been evolving professionally and philosophically since the publication of your last book?

PG: Well, I’ve gotten involved in a whole bunch of stuff that mainly has to do with being the grandfather of 11 grandchildren.And that has taken away the drive and the energy to write another book. But it’s been worth it. I mean, the kids are terrific and watching them—my oldest grandchild is 19 now and my youngest is 15 months—watching them continues to teach me about myself in ways that are very important. But I’ve been thinking, you know, not a bad idea to start getting back to some of that.

RW: Do you have another book in you? And if so, what would be the message of that book?
PG: I think the ideas that are in The Evaluation and Treatment of Marital Conflict, book that we put out in the middle ‘80’s, and even some of the stuff that was in the original textbook you were talking about before, are only partially developed. I think that the concepts develop most clearly when you’re putting them to the test with your students. And we still do that, but not with the kind of intensity and frequency that we used to. In recent years as managed care has come in, training programs are kind of atrophying. There used to be a battle between five or six models of doing things, and the debate and the discussion and the application to clinical situations of the models were very enriching, very enlightening, very energizing.If I was going to put another portion of my energy into my work as opposed to my grandchildren—they’re going to probably tell me to do that pretty soon—I would try to work towards applying the models that were developed in the late ‘80’s and early ‘90’s and see if they can hold up, you know? Try to make distinctions between ‘70’s and ‘80’s versions of intimacy and attachment and present day. Are they different? What are the differences? Can there be an evolution that provides more refined and sharper models that improve clinical outcomes?

Flying-By-the-Seat-of-Your-Pants Therapy

RW: And would you include integrating the various models?
PG: I think as much as they can be integrated, yeah, absolutely. I think that there’s a need for that. And the question is how do you do the integration without getting the lowest common denominator? And I think that some concepts go together and others don’t. But it’s rare that there’s been one way of thinking about these things. Ego psychologists had a structural way of approaching things just like Minuchin and others have had a structural way of approaching things, you know? And I think that the analytic psychodynamic models really evolved into the multi-generational systems whether it’s Bowen and Fogarty and myself and Carter and Monica and all those folks or if it’s a more strictly psychodynamic approach to things, or Haley and some of those people who really came out with a totally different perspective.So all that stuff that was done kind of side-by-side in the ‘70’s and the ‘80’s. I think if people had time and the interest in the information, more developing could take place. And hopefully that development would provide a refinement that could be taught to people that are doing therapy because it seems like folks are flying by the seat of their pants a lot in doing therapy these days.

Some of therapy has kind of dwindled down to giving advice, you know, from your own particular perspective, which isn’t bad unless it’s the only thing you know. I would love for a day to return where people were working together to define models and refine them and make them reproducible.

Maybe that’s not possible in this time-crunched era that we’re in now, but I would like it.

RW: Many people are calling for a broader dissemination to people. The APA, for instance, is looking for ways to teach psychology outside of clinics, hospitals, private practice and academic settings, using the internet, for example. What are your thoughts about that?
PG: I am intrigued by it. I think folks my age are a little intimidated by the technology, but I think it’s crucially important. What my kids can do with a computer in terms of scope and rhythm and efficiency is so far ahead of what I can do. The grandchildren are even better at it.
RW: I agree and I’m glad to hear it. Are there any final thoughts you would like to share before we close?
PG: Well, I think that making the family of origin work relevant is important, without trying to shove it down people’s throats. A long time ago in our work we saw it as essential to not try to sell a particular approach, but to start with where clients are feeling the pinch, where they’re feeling the pain, and to proceed in a way that first and foremost helps them with their symptoms—whether that’s prescribing medication or using cognitive techniques or incorporating family system theory into the work.And then continuing to check back in with them about what makes sense for them because they’re putting in time and putting in money, so they ought to have some say about where our focus is and where we’re trying to take them.
RW: That makes good sense. Thank you so much. I have greatly enjoyed our discussion and appreciate your body of work and your willingness to share this with us now.
PG: Well, thank you for asking me.

Reid Wilson on Strategic Treatment of Anxiety Disorders

Posted on 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.

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.

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

Posted on 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 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.