Basic Skills in

Psychotherapy
and Counseling

Christiane Brems
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Basic Skills in
Psychotherapy and
Counseling

Christiane Brems, Ph.D., ABPP

University of Alaska Anchorage

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Library of Congress Cataloging-in-Publication Data

Brems, Christiane.
Basic skills in psychotherapy and counseling / Christiane Brems.
p. cm.
Includes bibliographical references and index.
ISBN 0-534-54942-X
1. Counseling. 2. Psychotherapy. I. Title.
BF637.C6 B722 2000
616.89'14—dc21
00-057972

This book is printed on acid-free recycled paper.

To the women who have shaped my life-
My beloved mother, Rosemarie Brems
My adorable grandmother;
Carolina Hilsheimer
My caring sister, Gabriele Strubel
and in the memory of Emmi Brems
Contents

Listing of Figures and Tables xv

Preface xvii
Acknowledgments xxiii

Part One

Preliminary Issues 1

Chapter One

Traits of Successful Therapists and Counselors 3

Issues in Choosing a Career in Mental Health 3
Disciplines, Degrees, and Related Credentials Relevant
to a Career in Mental Health 4
Motivations Underlying the Choice of a Career in Mental Health 10
Skill Development Recommendations 15
Personal Traits Relevant to the Practice of Psychotherapy
and Counseling 16
Facilitating Traits of Mental-Health-Care Providers 19
Hindering Traits of Mental-Health-Care Providers 27
Countertransference Issues 31
Skill Development Recommendations 34
The Next Step: Necessary Skills for Mental-Health Practice 34

\11
Vlll CONTENTS

Chapter Two
Self-Awareness Skills 38
Values Clarification 39
Mandatory Versus Aspirational Ethics 40
Individual Self-Awareness 43
Common Therapy and Counseling Topics That Involve Values
Interpersonal Self-Awareness 48
Skill Development Recommendations 49

Cultural Competence and Sensitivity 52

Cultural Awareness 55
Cultural Knowledge 61
Cultural Skills 65
Skill Development Recommendations 69

Chapter Three
Self-Care Skills 70
Self-Exploration and Awareness 71
Personal Therapy or Counseling 72
Inner Work 72
Meditation 73
Skill Development Recommendations 77

Relaxation and Centeredness 77

Breathing Exercises 77
Mindfulness Practice 79
Relaxation Exercises 80
Guided Imagery 82
Skill Development Recommendations 83

Healthy Personal Habits 83

Nutrition 83
Physical Activity 89
Rest 90
Physical Self-Awareness 91
Involvement with Nature 92
Skill Development Recommendations 93

Attention to Relationships 94
Skill Development Recommendations 95
 CONTENTS IX

• Recreational Activities 96
Skill Development Recommendations 97

Part Two

Skills to Facilitate Communication

in Psychotherapy and Counseling 99

Chapter Four
Attending Skills: Nonverbal Communication and Listening 101
Nonverbal Communication 102
Interaction of Verbal and Nonverbal Communication 102
Components of Nonverbal Communication 103
Helpful Hints for Nonverbal Communication 115
Skill Development Recommendations 117
Listening Skills 117
Roadblocks to Listening 118
Essential Skills for Good Listening 121
Skill Development Recommendations 124

Chapter Five
Questions to Encourage Communication 126
General Guidelines About Questions 129
Pitfalls in the Use of Questions 129
Examples of Clinicians’ Reasons for Controlling or Intrusive
Questions 136
Additional Thoughts About the Use of Questions 144

Open-Ended Questions 144

Sample Transcript of Open-Ended Questions 147
Skill Development Recommendations 148

Systematic Inquiry 149

Sample Transcript of a Systematic Inquiry 150
Skill Development Recommendations 154
X CONTENTS

Chapter Six
Response Types: Verbal Communication
and Client Disclosure 155
Encouraging Phrases 156
Sample Transcripts for Encouragers 157
Skill Development Recommendations 158
Restatements and Paraphrases 158
Sample Transcripts for Restatements and Paraphrases 161
Skill Development Recommendations 164
Reflections 164
Sample Transcripts of Reflections 166
Skill Development Recommendations 168
Interfacing Response Types 168
Guidelines for When Best to Use Which Response Type 169
Sample Transcripts for Interfacing All Response Types 170
Summarization 173
Sample Transcripts of Summarization 175
A Few Final Comments 177
Skill Development Recommendations 178

Chapter Seven
Moving Beyond Simple Communication:
The Process of Empathy 180
Empathy—Preliminary Issues 181
Prerequisite Traits and Skills for Optimal Empathic Skillfulness 182
Empathic Skillfulness as a Cyclical Process 183
The Phases of the Cycle of Empathic Skillfulness 186
Sample Transcript of a Cycle of Empathic Skillfulness 194
The Additive Nature of Empathic Skillfulness 197
Level One and Level Two Responses: Empathic Failure Versus Optimal
Empathic Failure 199
Level Three Responses: Reflection Versus Empathy 203
Level Four and Level Five Responses: Imposing a Viewpoint Versus
True Empathic Skillfulness 204
Samples of Level One to Level Five Responses 205
Skill Development Recommendations 210
 CONTENTS XI

Part Three

Skills for Cognitive Awareness

in Psychotherapy and Counseling 213

Chapter Eight

Working with Thought and Cognition:

Overview and Basic Skills 215
A Model for Conceptualizing Working with Thought
and Cognition 216
The Process of Normal Cognitive Development
and Implications for Therapy and Counseling 217
A Hierarchy of Interventions and Strategies for Working
with Thought and Cognition 222
Dealing with Clients’ Cognition-Related Crises
in Session 223
Basic Strategies for Working with Thought and Cognition 226
Imparting Information 227
Sample Transcript of Imparting Information 231
Pointing Out Patterns 235
Asking Clarifying Questions 240
Skill Development Recommendations 245

Chapter Nine
Working with Thought and Cognition:
Advanced Interventions 247
Establishment of a Context for Advanced Cognitive
Intervention 248
Step One Toward Building Context 249
Step Two Toward Building Context 251
Step Three Toward Building Context 252
Step Four Toward Building Context 255
Confrontation 256
Basic Mechanics of How to Use Confrontation 258
Guidelines for the Use of Confrontation 259
Sample Transcript of Confrontation 260
Skill Development Recommendations 264
\11 CONTENTS

Here-and-Now Cognitive Processing 264

Basic Mechanics of Here-And-Now Process Comments 267
An Outline for Processing Here-and-Now Events 270
Recognizing and Utilizing Opportunities for the Use
of Here-and-Now Process Comments 271
Sample Transcript of Here-and-Now Process Comments 273
Interpretation 276
Skill Development Recommendations 277
Assumptions Underlying the Use of Interpretations 277
Factors to Consider When Using Interpretations 279
Guidelines for Using Interpretations 282
Sample Transcript of Interpretation 283
Skill Development Recommendations 287

Part Four

Skills for Affective Awareness

in Psychotherapy and Counseling 289

Chapter Ten
Working with Affect and Emotion:
Overview and Basic Skills 291
A Model for Affective Awareness and Inner Experience 293
Level One: Basic Awareness of Affect 294
Level Two: Basic Inner Experience of Affect 296
Level Three: Labeling of Basic Affect 296
Level Four: Identification of Default Affect 298
Level Five: Identification of Affect Intensity 298
Level Six: Identification of Mixed and Conflicted Affect 299
Level Seven: Identification of Underlying Affect 300
Level Eight: Acceptance of Affect 302
Level Nine: Understanding of Affect 303

A Model for Affective Expression 304

Step One: Conscious Outward Expression 305
Step Two: Ritualized Outward Expression 307
Step Three: Congruence with Level of Intensity 308
Step Four: Congruence with Type of Emotion 308

Facilitating Clients’ Affective Experience and Expression in Session 309

 CONTENTS xiii

Dealing with Clients’ Affect in Session 311

Dealing with Loss of Control Over Emotion 312
Dealing with Uncontrollable Crying 313
Dealing with Strong Anxiety Reactions and Panic 314
Dealing with Anger and Hostility 315
Dealing with Depersonalization and Dissociation 317
Skill Development Recommendations 319

Chapter Eleven
Working with Affect and Emotion: Focus on the Body 320
Focus on the Breath 321
Basic Breathing Exercise at Level One of Inner Experience 324
Advanced Breathing Exercise at Level Eight of Inner Experience 329
Skill Development Recommendations 333
Focus on the Body 332
Bodily-Awareness Exercise 333
Body Attunement Exercise 340
Skill Development Recommendations 348
Focus on the Bridge Between Body and Affect 348
Basic-Bodily-Experience Exercise 348
Advanced-Bodily-Experience Exercise 359
Skill Development Recommendations 365

Chapter Twelve
Working with Affect and Emotion: Focus on Feelings 366
Focus on the Experience and Identification of Affect 367
Here-and-Now Affect Exploration Exercises 369
Affect Continuum Exercise 379
Skill Development Recommendations 383
Focus on the Acceptance and Understanding of Affect 383
Progressive-Muscle-Relaxation Exercise 386
Focusing-Relaxation Exercise 393
Skill Development Recommendations 397

Final Thoughts 397

References 399
Author Index 411
Subject Index 415
 ■

'

'

.
'

.
Listing of Figures and Tables

Figures
1-1 Diagram of Therapeutic Competence 36
7-1 The Five-hhase Cycle of Empathic Skillfulness 187
10-1 A Flowchart for Assessment of Level of Affective
Awareness and Inner Experience 295
10-2 A Flowchart of Questions for Assessment of All Aspects
of Affective Expression 306
Tables
1-1 Career Options for Mental-Health-Care Providers 6
1-2 Motivators for Entering a Career in the Helping Professions 12
1-3 Personal Traits that Facilitate Mental-Health Treatment
and Rapport 20
1- 4 Red Flags for Issue-Specific, Trait-Specific,
or Stimulus-Specific Countertransference 30
2- 1 Rokeach s Central Life Values 48
2-2 Interpersonal Patterns to Explore to Gain Interpersonal
Self-Awareness 50
2- 3 Traits of a Culturally Sensitive Mental-
Health-Care Provider 56
3- 1 Suggested Guidelines for Healthy Nutrition 86
4- 1 Knapps (1978) Conceptualization of the Interaction
Between Verbal and Nonverbal Communication 104
4-2 Samples of Possible Interpretations of Common Kinesics 107
4-3 Sample Pitfalls in Nonverbal Expression 112
4-4 Congruence in the Verbal and Nonverbal Expression
of Important Clinician Traits 116
4-5 Roadblocks to Effective Listening 121
4- 6 Helpful Hints for Accurate Active Listening 125
5- 1 Comparison of the Three Types of Questions 128

xv
XVI LISTING OF FIGURES AND TABLES

5-2 Positive and Purposeful Uses of Closed Questions 142

5-3 Purposes of the “Question Words” 145
5- 4 Topics for Systematic Inquiry in an Intake Interview 151
6- 1 Comparison of the Primary Response Types 174
7- 1 Differentiation of Trait Empathy From Similar
Clinician Traits 184
7- 2 Essential Traits and Skills That Facilitate the Various
Phases in the Cycle of Empathic Skillfulness 188
8- 1 Piagets Stages of Cognitive Development 218
8-2 A Hierarchy of Cognitive Strategies and Interventions 221
8- 3 Imparting Information: Psychoeducation, Normalization,
and Relabeling 228
9- 1 Categories and Examples of Client Inconsistencies
and Discrepancies 257
10- 1 Factors to Consider in Facilitating Catharsis 312
11- 1 Inner Affective-Experience Exercises: Application
and Purpose 322
12- 1 Feeling Words Categorized by Type of Affect 370
Preface

I have just three things to teach:

Simplicity, patience, compassion.
These three are our greatest treasures.
Simple in actions and in thoughts,
You return to the source of being.
Patient with both friends and enemies,
You accord with the way things are.
Compassion toward yourself,
You reconcile all beings in the world.
The Tao Te Ching

Dear Reader:
Thank you very much for holding this book in your hands and reading these
words, regardless of whether you have already purchased the text or whether
you are still evaluating if you would like to buy it. It was my pleasure to write
this book and I would like to take this opportunity to share why I made the de¬
cision to write it and why it may be useful to you, the reader.

Why Did I Write This Book?

As you and I are well aware, many books are on the market today that teach
about basic skills in counseling and psychotherapy. Was there really a reason for
yet another? The answer to this question in my mind was an unequivocal “Yes,”
for a number of reasons. For years I have been searching for a book that would
be useful for a beginning course in psychotherapy or counseling that would be
sophisticated yet pragmatic, dense with knowledge yet readable, and compre¬
hensive yet appropriate for a single semester. Clearly there are sophisticated,
comprehensive, and fact-packed books on this topic; I own many of them and
treasure them. However, for a simple beginners course, these large volumes
xvn
win PREFACE

are often overwhelming and so theoretical that the novice becomes flooded
with detail and in the process loses the human connection with the material
and the client. There are also books that are simple and straightforward, as well
as easy to read. Unfortunately, many of these texts fail to provide a clear frame¬
work for the simple skills they present, leaving students with fragments of skills
and without a context in which to apply them.
Thus, I have been searching for a book that would provide students with
all the basic information and knowledge necessary to engage in safe beginning
practice of counseling and psychotherapy; a book that would provide a context
or framework along with skills and detailed application. I was looking for a book
that would achieve this goal of giving context and application without forcing
students to sort through reams of research literature, which while certainly in¬
valuable and important to a students overall education, may detract from the
purpose of the type of course for which this book is written. Over and over
again I failed in my search. Finally, since I knew what I was looking for, I began
to shape a text that would have these very features. What grew out of this de¬
sire of mine for a simple yet sophisticated, scientific yet pragmatic book is the
product you now hold in your hands. It is a book that hopes to help students
deal with the most basic of issues of mental health practice by introducing them
to the basic skills necessary in counseling and psychotherapy work, embedding
these skills in a clear and logical framework that can be applied within virtually
any counseling or psychotherapy theory.

For Whom Did I Write This Book?

The audience for this book is upper-level undergraduate or graduate students
who are about to embark on a career in the mental-health professions. A wide
range of students can benefit from this text, including students in all of the fol¬
lowing mental-health-care fields:

• psychology
• counseling
• social work
• psychiatric nursing
• psychiatry
• marriage and family or relationship therapy or counseling
• child psychotherapy or counseling
• human relations and
• any other mental-health-care field

The book is targeted towards beginning students in anyone of these mental-

health fields. It is conceptualized as the primary text that would accompany a
basic course in psychotherapy or counseling skills. It will be invaluable to
novices in the mental-health field, but may also be a great resource for more
 PREFACE XIX

‘ advanced students who seek a summary text with many examples and sample
transcripts useful in direct client work. The book is best absorbed in its entirety
before the first client contact. Once the skills addressed in this book are mas¬
tered, the reader will be ready to see a first client. I would invite readers at that
point to turn to two of my other books to facilitate the continued journey in the
mental-health field. The two other books represent the sequels to this text and
build upon the basic skills presented here. They are Psychotherapy: Processes
and Techniques (Brems, 1999) and Dealing with Challenges in Psychotherapy
and Counseling (Brems, 2000). For readers who are interested in work with
children, A Comprehensive Guide to Child Psychotherapy (Brems, 1993; revi¬
sion to be released 2001) may be helpful.

What Is in This Book?

This book will prepare readers for beginning mental-health practice by giving
them an overall appreciation of counseling and psychotherapy, while also pro¬
viding all the microskills necessary to apply this deeper knowledge pragmati¬
cally and directly with clients. The book deals with all the critical topics that
need to be thought through by a counselor or therapist before embarking upon
therapeutic work with clients. As such, it covers the following basic areas of
information and skills:

• choosing a career in mental health: disciplines, degrees, motivations

• personal traits: traits that help, traits that hurt
• counter transferences: dangers, uses
• values clarification: personal and interpersonal self-awareness
• cultural sensitivity: awareness, knowledge, skills
. self-care: inner work, nutrition, health, exercise, relationships
• communication skills: nonverbal communication, listening, attending
. understanding affect and emotion: awareness, experience, expression
. dealing with affect and emotion: dealing with crisis, catharsis
• working with affect and emotion: using the body, using feelings
. understanding thought and cognition: normal cognitive development,
cognitive processing levels
. dealing with thought and cognition: dealing with crisis
. working with thought and cognition: simple strategies, advanced
interventions

The text provides an overall easy-to-understand framework for mental-

health practice, in a fresh format. Within that framework it deals with many ba¬
sic building blocks of counseling and psychotherapy that traditional texts have
included for decades. Some of the traditional approaches covered in the text
include:
XX PREFACE

• nonverbal communication
• listening skills
• attending skills
• use of silence
• encouragers
• restatements and paraphrases
• reflections
• summarizations
• open-ended questions
• systematic inquiry
• breathing exercises
• relaxation exercises
• reframing and relabeling
• normalization
• pointing out patterns
• confrontation
• here-and-now process
• interpretation

The conceptualization of therapeutic competence that underlies this book

emphasizes the interplay between therapeutic skills and personal traits and
abilities. Figure 1-1 (in Chapter One) provides an overview of how personal¬
awareness skills, communication skills, affective skills, and cognitive skills in¬
teract and work together to create a competent counselor or therapist. Both in¬
structors and students will benefit from the reality that students will not only
be exposed to basic skills, as listed above, but will receive a solid framework
within which to apply these skills. They will benefit from the many case examples
and instructions that help them translate technical information into practical
terms and application. The clear and jargon-free writing, along with the many
summaries and tables, should help students easily understand information pre¬
sented and locate details needed at a later time. Finally, the many Skills Devel¬
opment Recommendations provided throughout will help instructors structure
course work and will encourage students to practice and explore the new skills
to be learned.

How Is This Book Special?

To summarize, this book has many special features that make it the perfect
accompaniment for basic counseling and psychotherapy skills courses. These
features include, but may not be limited to, the following advantageous
characteristics:

• clear and useful theoretical framework for all presented skills

• presentation of all traditional basic skills
 PREFACE XXI

• presentation of many basic skills not traditionally covered in basic-skills

books
• attention to personal issues relevant to counselors and therapists
• many examples and session transcripts
• clear instructions for skills and exercises
• many transcripts for exercises that can be used as written with clients
• self-contained sections that can be read in any needed sequence to adapt
to reader preferences
• scores of tables and lists that clearly summarize material for easy and
quick reference
• clear and uncomplicated wilting style
• no ties to a particular conceptual approach to counseling or psychotherapy
• tailored Skills Development Recommendations to help students practice
and master basic skills
• thorough subject and author indexes

Thank you for selecting or considering this book. I wish you an enjoyable
career in mental-health care and hope this text will prove to be a helpful
companion.
Sincerely,
Christiane Brems, Ph.D., ABPP
 »

\
Acknowledgments

There are always many people to thank when a book comes to fruition. I want
to start by expressing my undying gratitude to the love of my life and my best
friend, Mark E. Johnson. Thank you for reading every draft of every page of this
project and for your patience with my preoccupations and obsessions in writ¬
ing this and other books. Thank you for being the centering presence in my life.
My appreciation also goes as always to my wonderful German family, who
has supported me all of my life, even after I moved thousands of miles away to
a new life in a new country. Your love and caring mean the world to me. I am
grateful to all of you: Bernhard Brems, Rosemarie Brems, Lina Hilsheimer,
Gabriele Strubel, Hans Juergen “Floh” Strubel, and Jan Strubel. Thanks for
being who you are.
Thank you, the students in the clinical-psychology program at the Univer¬
sity of Alaska Anchorage, who have helped create a joyous and stimulating
world of teaching. My gratitude goes to all of you for your enthusiasm for do¬
ing therapy, your enjoyment of learning, and your wide-eyed excitement for
what I had to offer you. I know you will go on to do great things!
Finally my appreciation goes to the editing and proofreading team that
helped shape this book into its final form. Thank you, Julie Martinez and Caro¬
lyn S. Russ. And to the reviewers for their helpful and insightful feedback.
Thank you, Rachell N. Anderson, The University of Illinois at Springfield;
Alisabeth Buck, Tacoma Community College; Bob Egbert, Southern Adventist
University; Harold Engen, University of Iowa; Joshua Gold, University of
Southern Carolina; Jeffery S. Haber, Metropolitan State College of Denver;
and Martha Sauter, McLennan Community College. This book could not have
become what it is without your help.

xxiii
 ■

0
Preliminary Issues
t
Traits of Successful chapter

Therapists
and Counselors

This is what should be done

By one who is skilled in goodness,
And who knows the paths of peace:
Let them be able and upright,
Straightforward and gentle in speech.
Humble and not conceited,
Contented and easily satisfied.
Unburdened with duties and frugal in their ways.
Peaceful and calm, and wise and skillful,
Not proud and demanding in nature.
Let them not do the slightest thing
That the wise would later reprove.
From the Buddha’s Metta Sutra

The field of mental-health care offers many exciting career paths, as well as the
potential for great personal career satisfaction. However, it is not an easy life-
work to choose as the professional will be invariably and profoundly affected by
this type of work on a personal and professional level. There are probably few
careers that affect their practitioners as profoundly and personally as does a ca¬
reer in mental health. Equally, few career choices are as affected by personal
aspects of the practitioner. Given the great importance of the personal to the
professional and the professional to the personal, an in-depth exploration of the
person who is considering a career in mental health is in order.

Issues in Choosing a Career in Mental Health

Careers in mental health are quite diverse. An informed decision as to which

career path to follow will be based on a study of the academic fields devoted to
psychotherapy and counseling, terminal-degree requirements, credentialing
3
4 CHAPTER ONE

requirements, and the student s motivations for choosing a career in the help¬
ing professions. The major fields that have devoted themselves to psychotherapy
and counseling are psychology, psychiatry, counseling, and social work. At least
two important offshoots of these primary fields that have gained independence
over the years are the fields of marriage and family counseling or therapy, and
human services. Different disciplines within the area of mental health have dif¬
ferent graduation and credentialing requirements. Graduation requirements
are generally driven by terminal degrees within a field as well as highly idiosyn¬
cratic variations in curricula across states and schools. Credentialing require¬
ments (certifications and licensure) similarly differ greatly depending on where
practitioners set up a practice and what degree path they chose originally. The
motivation students have for choosing a career in the helping professions is
equally important to explore. Despite the clear need for such exploration, this
is a practice that does not seem to happen automatically. This chapter will guide
students toward a thorough exploration of their career choice as well as per¬
sonal issues that may enter the practice of their careers once they have made a
conscious choice about which particular route to choose.

Disciplines, Degrees, and Related Credentials Relevant

to a Career in Mental Health
It is not the purpose of this book to help mental-health professionals choose the
best career path; it is, however, devoted to providing the tools for a successful
career as a psychotherapist or counselor. Fundamental to their success is mak¬
ing appropriate academic choices. It is not uncommon for young professionals
to choose an academic path based on guidance from important external sources
such as parents, teachers, and college professors, without careful review of all
the options. Some graduates may choose psychology because their local univer¬
sity does not offer a counseling degree program; some may choose social work
because a parent was a social worker. Choosing the academic field of study—
that is, psychology versus social work and so on—can have major implications
about the terminal degree to strive for. In some disciplines, such as social work,
the masters degree is an excellent option as it is the accepted terminal degree
within that profession. In other disciplines, such as psychology, a doctorate may
be required to carry out certain functions, whereas a masters degree may
suffice to engage in other duties. In yet other fields, the differentiation between
the master’s degree and doctorate in terms of implications for mental-health
practice may be rather vague or may merely set apart the practitioner from the
teacher or researcher. This is true, for example, in counseling and marriage and
family work.
It is not uncommon for graduate students to have certain career aspirations
that are not entirely commensurate with their degree choices. For example, fre¬
quently graduate students in psychology want to work strictly as counselors
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 5

or psychotherapists in a general mental-health setting such as a community

mental-health center. Yet these very same future professionals are enrolled in
rigorous doctoral programs training them also to be researchers and teachers.
Such individuals might be better served in a rigorous masters program in psy¬
chology or counseling that trains them to do what it is they aspire to. These stu¬
dents may never have understood their options or alternatives. Table 1-1 out¬
lines the major disciplines that train mental-health professionals'. Within each
discipline, the table breaks out various degree options (if applicable), as well as
possible licenses and credentials compatible with the degree choice. It also
shows the ultimate responsibilities that can be carried out by professionals in
these fields of interest, again differentiating levels of education. The table is
strictly concerned with post-baccalaureate training and career choices requir¬
ing a graduate education, hence it does not include paraprofessional counsel¬
ing fields.
The reader will notice in Table 1-1 that social work, marriage and family
training (counseling or therapy), and counseling as professions have strongly
endorsed and supported the masters degree as one of two terminal degrees
(the other being the doctorate). In all three disciplines, masters degrees lead to
nationally accepted (though state-granted) licenses, namely, the licensed clini¬
cal social worker (LCSW), licensed marriage and family therapist (MFT), and
licensed professional counselor (LPC), respectively. Psychology, on the other
hand—or, perhaps more accurately, the American Psychological Association
(APA)—has rejected the masters as a terminal degree for purposes of inde¬
pendent licensure and practice in psychology. Despite this official stance of the
American Psychological Association, however, many states in the United States
and provinces in Canada have developed licenses for psychological practice at
the masters level. Yet, there is no standard label for this masters level license
(examples including psychological associate and psychometrician), nor a stan¬
dard for scope of practice of these providers. Some states, such as Alaska, allow
the care provider to practice completely independently after a certain number
of years; some require irregular supervision regardless of how long the masters
level provider has been in practice; some (in fact, perhaps most) require weekly
supervision of masters level practitioners. This reality has made the masters
degree a more desirable degree in the disciplines of social work, counseling,
and marriage and family, where this level of education leads to clear and undis¬
puted licenses.
It is an unfortunate reality for the discipline of psychology that the mas¬
ters degree is not an officially endorsed degree. Movements are under way to
change that. For example, the Northamerican Association of Masters in Psy¬
chology (NAMP) has developed and implemented accreditation procedures
for academic programs in psychology at the masters level. It is not yet clear
how successful this movement will be in elevating the masters in psychology to
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 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 9

step in the right direction (see also Brems and Johnson, 1996a). For the time
being, LCSWs enjoy many privileges and advantages from which masters
level practitioners in psychology tend to be barred. Most importantly, LCSWs
are generally fully reimbursable by third-party sources such as insurance and
Medicaid, tend to hold high-responsibility administrative positions, and can
practice independently without supervision. Even LPCs and MFTs have more
freedom than master’s level psychological associates, though they do not enjoy
some of the privileges of LCSWs. For example, third-party payment eligibility
differs from state to state.
Another interesting development is reflected less obviously in Table 1-1.
Although there are still two primary fields within the discipline of psychology
that provide mental-health services—namely, clinical and counseling psychol¬
og)7 (the latter not to be confused with degree programs in counseling)—the
actual practice and career paths of the graduates from these two fields differ
very little. The differences between clinical and counseling psychology appear
relatively minor and the similarities are growing. Both have similar curricula,
career paths, and clienteles. One of the few major differences that appears to
remain is the fact that most doctoral programs in counseling psychology prefer
for their applicants to have completed a master s degree, whereas most clinical-
psychology programs prefer their applicants to apply straight out of an under¬
graduate program. Another minor difference emerges with regard to career
counseling, which appears to remain largely within the realm of counseling
psychology. The interested reader should peruse the extensive literature about
clinical versus counseling psychology before making a final decision about
which to choose (for example, Brems and Johnson, 1996b, 1997; Brems, John¬
son, and Galluchi, 1996; Johnson and Brems, 1991).
It is also notable that both social work and psychology have discipline-spe¬
cific (D.S.W, Psy.D.) as well as generic (Ph.D.) doctorates. There is generally
no difference with regard to licensure or other certification eligibility between
a discipline-specific and generic doctorate (especially if granted by a profes¬
sionally accredited program). However, within psychology, it appears to be true
anecdotally that Psy.D.s may have more difficulty than Ph.D.s in being hired for
academic positions in traditional Ph.D.-granting psychology doctoral programs.
Like medical professionals, psychologists have the option for board certifica¬
tion by the American Board of Professional Psychology (ABPP). Unfortunately,
unlike in psychiatry, only a small percentage of psychologists choose to pursue
board certification, which involves a rigorous examination process. Psycholo¬
gists (this label always implying a doctorate) are always eligible for third-party
reimbursement. In some states or communities, they may have hospital privi¬
leges and may be able to initiate hospitalization. This is also true for D.S.Ws
and, in some states, for LCSWs. Only psychiatrists, however, are able to pre¬
scribe medications. Only psychologists are fully trained to conduct indepen¬
dent psychological assessments (testing batteries).
10 CHAPTER ONE

Motivations Underlying the Choice of a Career

in Mental Health
The relatively objective and informed selection of discipline and educational
level does not suffice in and of itself to assure a successful career in the field of
mental health care. It will be equally important to take a look at more personal
issues that may ultimately affect each individuals success as a counselor, social
worker, or psychotherapist. One basic question deals with why, beyond the ob¬
jective criteria covered in Table 1-1, an individual has chosen to enter a help¬
ing profession. Personal motivations for entering the mental health field can be
helpful or harmful; most importantly, a practitioner must be clear as to why the
choice was made and how those personal reasons may enter into the work itself.
All career choices involve an underlying set of motivators that steer the in¬
dividual in a certain professional direction. Students interested in the workings
of nature or with a curiosity about what makes things work may be motivated
to focus their careers on physics, geology, or similar disciplines. Students widi
a history of medical concerns or with family experiences that involved illness
and perhaps death are often drawn to the medical profession. Individuals who
have always enjoyed and been rewarded for artistic self-expression may choose
theater or music. What then are typical motivations for people who choose a
career in mental health? A few motivations emerge on a regular basis. It is im¬
portant to recognize how different motivations may affect the choice and prac¬
tice of the profession; some motivations may affect the practice of helping in
positive ways, some in negative ones. Equally important, the same motivator in
two different care providers may manifest in uniquely different ways in their
work, being conducive to good work in one and intrusive for the other. Thus,
as the reader peruses the various motivations offered below, the main issue is
to evaluate each with regard to its truth for that individual and with its poten¬
tial impact on her or his relationship with clients. The Skill Development Rec¬
ommendations later in this chapter will revisit this issue further; a helpful sum¬
mary, addressing issues useful to self-appraisal, is provided in Table 1-2.
As indicated in Table 1-2, one important motivator that commonly emerges
is the desire to help. This motivator may have developed in various ways, but
often harks back to a helping role within the practitioners family of origin. In
other words, the career choice is often based on continuing a role that is famil¬
iar and perhaps enjoyed by the individual. If enjoyed, the desire to help can be
a powerful positive influence in the practitioners career; if perceived as burden¬
some, it will certainly get in the way. For some clinicians, the original desire to
help was a positive force early in the career; as successes and burdens mount,
however, the stresses of always being in the helping role may become over¬
whelming. If the desire to help is the main motivating force in the choice of this
career path, it will be important for the mental-health-care provider to choose
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 11

self-care skills outside of work that recharge and rejuvenate. Practitioners mo¬
tivated by this desire may be advised to avoid doing a lot of volunteer work in
their spare time.
Another common motivator is the desire to change the world. Although this
desire is often accompanied by the desire to help, the two are not entirely syn¬
onymous. The desire to change the world implies that the clinician wants to have
an impact on a wide range of people and wants to create change that ripples
through the social structure and system on a grander scale. This desire can af¬
fect work positively and negatively. It may lead a clinician to work with huge
caseloads to bring a message to as many individuals as possible. This approach
to changing the world one person at a time is a recipe for burnout. Other men¬
tal-health-care providers may be able to find paths that are less stressful, work¬
ing in administrative or political-action settings that by definition affect more
people but no longer involve direct work with individual clients. One danger in
the desire to change the world rests in the failure to do so on a large scale,
which to individual practitioners may feel like a failure in their careers.
The desire to have a purpose or to be needed can be another powerful mo¬
tivator for choosing a mental-health career. The creation of meaning in life is a
powerful force that is met for many through their work. Individuals who con¬
sider entering a helping profession often perceive the field as a means of fulfill¬
ing their desire to be needed and to have a purpose. The sense of being needed,
in turn, is often perceived as a means of assuring that a practitioners existence
on earth has meaning and purpose. However, being needed can, in the long run,
become draining and exhausting. If the mental-health-care provider always gives
and never receives, burnout is inevitable. What may have seemed a way to
achieve a sense of purpose and meaning may in the end be the opposite, leading
the clinician to a sense of loss and disillusionment. On the other hand, for many
helping professionals, it is the desire to be needed and the creation of meaning
in their lives through their work that brings them the greatest satisfaction.
These caring individuals thrive on providing for others and are true expressions
of altruism and compassion in action. What tends to mark these successful pro¬
fessionals is their ability to create support and compassion for themselves
through meaningful relationships and activities in their private lives.
Another powerful motivator for entering the mental-health field is a per¬
sonal struggle with emotional or psychological problems. There are practition¬
ers who enter the field to heal themselves, though this motivation may be hid¬
den even from their own awareness. They seek to find the solution to their
unhappiness through the educational and later the professional process, only to
find that this may not be the answer. This motivation is very similar to what
Day (1995) called the desire to do for clients what clinicians wish someone
had done for them. No doubt, entering a graduate education in mental health
challenges the student to explore the self and personal history. However, this
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14 CHAPTER ONE

self-exploration is most successful if based upon a solid foundation of a rela¬

tively healthy and integrated self. Those students who enter with fragile selves
may not be able to withstand the pressures of graduate school or the real world
once engaged in practice. The issue of wounded healers has come to the fore¬
front in recent years, and most associations of mental-health professionals have
begun to address this concern. Entry into these professions based on the de¬
sire for self-help may not be sound decision making.
Closely related to the desire to heal the self is the desire to enter the pro¬
fession to give to others what was personally experienced. Day (1995) called
this motivation the desire to do for others what someone else has done for the
clinician in the past. These individuals enter the mental-health field because
they have had emotional or psychological problems in the past, which they have
mastered through some form of counseling or therapeutic intervention. They
are now motivated to give back to others what they believe has saved them.
This motivation is noble indeed and can provide practitioners with exquisite
sensitivity for their clients. The potential pitfall is that these clinicians may
push the approach that worked for them, not recognizing that it may not be op¬
timal for all clients.
Another related motivator for choosing a mental health profession may be
the desire to share knowledge and wisdom. This desire is closely related to the
wish to be helpful, but is guided primarily by the belief of clinicians that they
have special insights or awareness that are useful not only in their personal lives
but also in the lives of others. This motivation can be powerfully useful if ap¬
plied in an open-minded and exploratory manner. The clinician may function
from an excellent base of knowledge and may indeed have developed many
useful insights and a great deal of wisdom. However, if the clinician believes
that the personal insight or awareness has to be applied in a certain way (that
is, in the way it worked for her or him), this motivation can lead to rigidity and
the imposition of goals and solutions that are not necessarily shared by or help¬
ful to the client. This clinician may coerce certain behaviors in the client or end
up giving advice. Failures on the part of the client to then follow through with
the clinicians suggestions may lead the mental-health-care provider to feel
frustrated and angry with the client.
Not easily admitted to self and others is the desire to enter the helping pro¬
fession to gain control and to tell others what to do. Nevertheless, this is a pow¬
erful motivator for some mental-health professionals. This motivator can take
a positive shape when the provider offers clear structure and guidance for cli¬
ents but the pitfalls are obvious. Clients do not need to be controlled and they
do not come to treatment for advice. They need to be understood and supported
in their own right and given permission to unfold their lives in their own de¬
sired direction. A controlling clinician who thinks the answers are clear and has
a specific piece of advice or a solution for every problem may not give the client
space to engage in this type of work and growth.
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 15

Skill Development Recommendations

Recommendation 1-1 Using Table 1-2, explore each motivation with re¬
gard to its likelihood of being true for you. Journal about how this motivation
has already manifested in your life, both positively and negatively. Think
about the worst-case scenario of this motivation playing itself out in your
cli n ical work and develop strategies of prevention.

Recommendation 1-2 Pick two of the professions listed in Table 1-1 that
most appeal to you and that most likely reflect your future career choices.
Then identify one p rofessional in your community for each of these profes¬
sions (by means of the Yellow Pages, for example, or recommendations from
your professors). Call each person and ask for an interview. Interview them
about the profession to explore whether your impression of and hopes about
the profession match with its reality. Then reconsider your career choices, ei¬
ther affirming your goals or revising them as needed.

Not often admitted, the desire for status and financial freedom can also en¬
ter into the decision to become a mental-health-care provider. Status is often
tied to advanced degrees, especially doctorates. This may lead students to
choose doctoral careers for all the wrong reasons. Financial gain is a potential
motivator for many professions. While many practicing mental-health-care pro¬
viders may laugh at the suggestion that financial gain is a motivator to enter this
field, the innocent student may make assumptions about money and prestige
that are not entirely grounded in the reality of the profession. Not surprisingly,
these practitioners will be disillusioned and dissatisfied when their careers fail
to provide for this basic need for recognition and advancement. A more devas¬
tating outgrowth of this desire is the impact it may have on the practitioner s re¬
lationship with clients. If prestige is not forthcoming outside the therapy room,
these practitioners may dominate and demand a respect from their clients that
is excessive. If financial freedom is threatened, these clinicians may choose to
keep a client in counseling, not because the person is still in need, but because
she or he has a great insurance company that keeps paying!
Most likely there are many other motivators that direct individuals to a ca¬
reer in mental health. Again, no single motivation is bad or good in and of itself.
Each merely has potential positive and negative impacts that need to be clear
in the clinicians mind. Any motivation, however positive, if misapplied can lead
to “pride rather than humility, insistence rather than invitation, telling rather
than listening, demanding rather than believing, or making and coercing rather
than letting” (Cormier and Cormier, 1998, p. 12). As will be noted below, almost
16 CHAPTER ONE

nothing about a provider is entirely positive or negative; what counts is the level
of self-awareness the individual professional has about personal motivations,
traits, and countertransferences. With good self-awareness, clinicians can learn
to make positive use of motivators and traits and can learn to transcend negative
aspects of both. Given the importance of self-awareness, self-awareness skills
will be dealt with in great detail later. However, now that the reader has ex¬
plored how personal motivations may play a role in career choice and how they
potentially affect the client-clinician relationship, it is important to turn to an
exploration of how other personal traits can enter into mental-health work.

Personal Traits Relevant to the Practice

of Psychotherapy and Counseling

The process of becoming a mental-health-care provider is challenging, repre¬

senting a path of development that can be highly intellectually stimulating, per¬
sonally gratifying, and interpersonally satisfying, on the one hand; and emo¬
tionally draining, personally devastating, and cognitively exhausting on the
other. The process of learning in the mental-health field progresses through
four stages, outlined beautifully by Lauver and Harvey (1997) as follows:

Stage One: Unconscious Incompetence At this stage the trainee is not yet
aware of the extent of the knowledge and skills required to become an effective
mental-health-care provider and blissfully moves along in training, unaware of
personal shortcomings and gaps in knowledge. Students at this stage often dem¬
onstrate a syndrome that could be called “I already know all of this.” Their mind
is often somewhat closed as they believe that their common sense and pure
motivation are sufficient to do the job of counseling or therapy. Being at this
stage is relatively easy for trainees because they have not yet come face to face
with their shortcomings and still feel blissfully happy about their career path
and choice. Fortunately for their clients, and for the clinicians and their super¬
visors, this stage invariably comes to an abrupt end as counselors or therapists
begin to recognize (or have pointed out to them by their supervisors) the lim¬
its of their personal knowledge, skills, and abilities. As limitations and counter¬
transferences (to be discussed in more detail below) rear their ugly heads, clin¬
icians recognize that there are things they need to learn, insights they need to
develop, and processes they need to become aware of. They are now entering
the painful Stage Two of the learning process.

Stage Two: Conscious Incompetence At this stage the trainee is aware of

limitations, both in the realm of knowledge and personality. Many students ac¬
tually begin the learning process at Stage Two, not Stage One (in a way miss-
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 17

‘ing out on the blissful state of unconscious incompetence). Clinicians at this

stage are very vulnerable and need to be supervised with care and caring as
they consolidate skills and form a professional self-image during a time of great
self-doubt. Conscious incompetence means being painfully aware of mistakes,
cringing when reviewing video- or audiotapes of sessions with clients, admit¬
ting errors in judgment, becoming aware of missed opportunities for interven¬
tions, recognizing poor choices of strategies, and most of all, realizing personal
traits that may hinder die work. This stage is painful, can lead to self-doubt, and
represents a true trial by fire. This stage, however, is also the experience that
leads students to a hunger for learning and a desire for good guidance and super¬
vision that is the mark of a healthy professional. A student in this stage, while
introspective and not always happy, is usually a pleasure to work with, seeking
new knowledge, reading, and consolidating learning almost twenty-four hours
a day. Clinicians who survive this stage with the help of a healthy foundation of
an integrated self and calming and supportive guidance from teachers and su¬
pervisors are then ready to consolidate their learning into a budding sense of
competence, the basis of Stage Three.

Stage Three: Conscious Competence At this stage, clinicians have

learned a lot, have developed a solid base of intervention skills, and have memo¬
rized the basics necessary to do good therapeutic work. They begin to be able to
tailor helpful treatment plans, and their interventions begin to be well-chosen
and well-timed. All this work, however, is done with great concentration and
effort; most choices and decisions are made deliberately and consciously. This
repetitive decision making and pondering leads the clinician to the point where
skills slowly begin to be integrated into a repertoire of strategies, and personal
traits begin to be tailored and modified into a useful way of being with clients.
The conscious effort and concentration required at this stage of learning means
a high expenditure of energy, and clinicians at this stage often leave work ex¬
hausted but happy. They have worked hard with their clients, but they have done
well and feel that something was accomplished. Where Stage Two was emo¬
tionally draining and challenging, Stage Three is cognitively exhausting and
stimulating. At some point, trainees will recognize that the work gets easier;
some skills begin to come almost automatically and not every intervention has
to be pondered and thought through in detail before being used. The clinician
is about to enter Stage Four.

Stage Four: Unconscious Competence At this stage, the mental-health¬

care provider has consolidated learning, has reached a healthy level of self-
awareness, has developed open-mindedness and flexibility, and no longer is
afraid of possible challenges presented by clients. Learning has become so in¬
grained and automatic that the work with clients is now second nature for the
clinician. Decisions are self-evident, and treatment plans easily emerge from
 18 CHAPTER ONE

the data collected from clients. The work with clients becomes a pleasure for
the clinician, and the strain and concentration of Stage Three begin to disap¬
pear. Clinicians can now work from a healthy emotional and cognitive plane.
- The biggest threat in this stage is that the clinician may slip into automatic pi¬
lot. Unconscious competence and automatic pilot are not the same thing. An
unconsciously competent clinician continues to seek out supervision or con¬
sultation, engages in careful self-care, reevaluates treatment decisions regu¬
larly, and reviews client charts on an ongoing basis. This clinician makes sure
that the ease of work is not confused with sloppiness or carelessness, nor with a
routine imposed on all clients regardless of their idiosyncratic needs and back¬
grounds. The positive traits a clinician brings to the profession will separate the
unconsciously competent care provider from the automatic pilot. Ongoing self-
awareness work is one aspect of the healthy clinician and will be addressed in
detail later. First, an overview of counselor traits is in order.
Each individual who chooses a mental-health career comes equipped with
personal traits and characteristics that influence the work to be done with cli¬
ents. Some of these influences may move the therapeutic process along (that is,
may be facilitators), whereas others may interfere. This exploration will begin
by highlighting traits that tend to be useful, if not critical, to success. It is im¬
portant for students to be honest in their assessment of the degree to which they
possess these particular traits. The glaring absence of several traits may point
toward the potential for problems. The occasional doubt about one or two, on
the other hand, may merely suggest that some personal work is needed.
It is important to note that this chapter differentiates skills from traits.
Traits are those characteristics mental-health-care providers bring with them
at the outset of their careers; they are the character traits and personal expres¬
sions developed over a lifetime of experience and interaction with others. Traits
may be innate, consciously developed, or inadvertently learned; they are what
is present and expressed right now. Skills, on the other hand, are those behav¬
iors (and possibly characteristics) that will be learned by the student over the
course of being in a mental-health training program (regardless of discipline).
They are the expressions and capacities of successful professionals that no in¬
structor will take for granted in a student, but instead will work consciously and
with effort to instill and teach.
Occasionally, it is difficult on the surface to differentiate a trait from a skill.
Empathy is an important case in point. Empathy will be presented in this chap¬
ter as a trait. However, it will also be dealt with in an entire chapter on empa¬
thy as a skill. In other words, there are basically two forms of empathy: die raw
trait that is incidentally developed (and thus preexisting) in the student, and the
refined set of techniques and conscious interventions that will be learned over
time. Most commonly, however, traits are clearly and easily differentiated from
skills. It is important to note that traits are not necessarily unalterable. They
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 19

'are, though, somewhat ingrained and will be acquired or eliminated only with
conscious work and effort.

Facilitating Traits of Mental-Health-Care Providers

A wide array of traits exists that can be very helpful to the therapeutic or coun¬
seling exchange between clients and clinician when present abundantly and
automatically. In turn, absence of these personal characteristics in the care pro¬
vider can have negative consequences for the client s treatment or the clinicians
level of career satisfaction and success. Table 1-3 gives an overview of the most
important personal characteristics a clinician can bring to therapy or counsel¬
ing. This table outlines how these traits can facilitate the process as well as how
their absence may negatively affect it. It needs to be reiterated that not all clin¬
icians ■will possess all of these traits to the same degree. Doubt about a few can
be overcome; the absence of several, on the other hand, is probably a red flag
for the student. A few of the more important traits will also be discussed below.
Self-esteem is an important trait as clients are not always enamored with a
clinicians techniques and procedures and may make their displeasure known
verbally by attacking the therapist. The insecure therapist may be worn down
by negative clients, whereas a healthy (and realistic) dose of self-esteem makes
the therapist less vulnerable to transferential and otherwise undeserved per¬
sonal attacks by clients (Brems, 1994). A therapist who cannot deal with the
temporary assault on her or his self-esteem in a session is bound for failure or
burnout (Kottler and Brown, 1992). An overall sense of competence is impor¬
tant as well (Cormier and Cormier, 1998), especially as clinicians experience
the self-imposed assault on their competence through increasing awareness of
what they do not yet know. A solid sense of general life competence is an ex¬
cellent trait to help beginning mental-health-care providers pass through the
stage of conscious incompetence. They will be able to recognize their continu¬
ing competence in other areas of their lives and can thus emerge into Stage
Three with healthy self-esteem and a heightened experience of competence
and clarity.
Self-respect is an important trait that assists clinicians in setting appropri¬
ate therapeutic boundaries with the client. Only self-respecting clinicians are
able to adhere to the agreed-upon time frame for a session without feeling
guilty, request payment as agreed upon, and refrain from accepting unneces¬
sary calls or contacts from clients between sessions. Such appropriate setting
of boundaries is actually very important for clients as it communicates control
and safety of the therapeutic setting. It is likewise crucial for mental-health-
care providers, as it takes care of their needs for a predictable schedule and pri¬
vate life outside of the clinic (cf., Herlihy and Corey, 1997, for a very complete
discussion of boundary issues).
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 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 23

The structuring oi therapy or counseling is also related to clinicians’ healthy

expression of power. Power, or expertness, is an important and useful trait if
wielded carefully and respectfully. Clearly, this trait can turn negative quickly
if over- or misused. Appropriate use of power means setting safety limits and
clear treatment boundaries. A balanced use of power means that the clinician
knows when to take responsibility and to create limits, boundaries, and struc¬
ture, and when to relinquish control so as not to coerce, manipulate, or force
clients (Cormier and Cormier, 1998). The trait becomes negative when it is
used to justify paternalism. The clinician is a guide, not a director, who func¬
tions on behalf of the client. Power is being abused if clinicians find themselves
directing their clients instead of allowing them to choose their own paths.
Therapists and counselors must have a high level of cognitive complexity.
Their work requires that they be able to conceptualize client cases and respond
quickly to situational issues. Clinicians must truly be able to “think on their feet.”
They must be knowledgeable and have the desire and ability to assimilate new
information quickly and to reason abstractly. Only a bright clinician can re¬
spond quickly enough to the quick outpouring of data that can occur in ther¬
apy and keep up with the client in terms of conceptualizing and revising treat¬
ment plans effectively (Cormier and Hackney, 1987).
Additionally, continuing to learn about therapy and related strategies is es¬
sential as the field changes continually (Egan, 1994). Striving for excellence is
how Kottler and Brown (1992) refer to the process of constantly learning and
increasing the therapists sense of awareness and therapeutic skill. Each new
client is viewed as a new learning opportunity that will stretch the therapist s
limits and broaden his or her horizons.
The clinician must also be fully competent in the ethical sense. Most, if not
all, mental-health professions have a code of ethics that requires that care
providers be fully trained, up to date, and generally competent at what they do
(Swenson, 1997). Counselors must know their professional limits and when to
refer to another provider when these limits have been reached by the demands
of a case or client. Further, new information emerges constantly as work pro¬
gresses. This requires flexibility that results in positive revisions of treatment
plans and conceptualizations, and adaptability of treatment strategies in a
meaningful manner (Morrison, 1995). Not all human beings are capable of
functioning in such an environment of ambiguity and tentativeness. Some will
attempt to make counseling or therapy fit a rigid model. No client, no family,
no therapy fits a specific mold (Land, 1998). In fact, the whole therapeutic pro¬
cess relies upon change, upheaval, tentativeness, and not uncommonly, ambi¬
guity. Related to the concept of flexibility is the idea that a good therapist must
have patience (Strupp, 1996). Counseling cannot be rushed, and counselors
cannot expect clients to follow a particular time line.
Mental-health-care providers need to possess a high level of willingness to
self-explore and a certain level of emotional maturity. Clinicians who fail to have
24 CHAPTER ONE

introspective abilities or tendencies are very prone to feelings and attitudes that
may confound the treatment process (cf., Knobel, 1990). Self-exploration, en¬
tered into willingly and regularly, helps prevent inappropriate countertransfer¬
ence reactions and helps the mental-health-care provider respond out of con¬
cern for the client, not for the self. Self-exploration is crucial to the ability to
recognize when a clinician’s personal needs have been mobilized in a thera¬
peutic relationship and to keep these needs out of the therapy room. Emotional
maturity helps counselors recognize that their own personal needs may need to
be addressed, and keeps them from doing so in the presence of the client (Knot¬
tier and Brown, 1992). Willingness to self-explore and introspect also helps
clinicians recognize the need to seek supervision and consultation. Emotional
maturity allows mental-health-care providers to improve and enhance self-
knowledge by seeking supervision and consultation, not only when personal
needs and limitations obviously rise to the surface (Strupp, 1996), but on a reg¬
ular basis to prevent inappropriate expression of personal needs in therapy ses¬
sions (Basch, 1980). Seeking self-knowledge through ongoing introspection
and self-exploration also means that clinicians practice what they preach, look¬
ing at themselves regularly with caring and realistic criticism (Egan, 1994).
Related to self-exploration and the ensuing higher level of self-awareness
is a clinicians ability to recognize when personal values may have intruded upon
treatment or the evaluation of a client. Since it is desirable not to impose val¬
ues on clients, the ability to recognize that it is happening, coupled with accept¬
ance and flexibility, is crucial to successful mental-health work (Choca, 1988;
Cormier and Cormier, 1998; Knobel, 1990).
Open-mindedness is an essential trait that helps clinicians welcome even
those clients whose values may differ from their own. Open-minded therapists
will not inadvertently or deliberately force personal values onto clients, espe¬
cially clients who grew up in an environment that was significantly different
from that of the therapist (Castillo, 1997; Pinderhughes, 1983). A difference in
backgrounds will not threaten treatment as long as the mental-health-care pro¬
vider can keep an open mind and is able to see the client’s life from the client’s
unique perspective. What the clinician may need to understand is that some
behaviors of the client that would be considered maladaptive or questionable
in the therapist s personal background, may have had great adaptive value in the
clients environment. Clearly, counseling cannot be entirely free of values and
value judgments (Lewis and Walsh, 1980; Pinderhughes, 1997). However, the
counselor is encouraged to be as flexible and open-minded as possible, and to
recognize personal values and how they may collide with the values of a client.
Remaining as nonjudgmental and compassionate about clients’ realities as pos¬
sible certainly facilitates the therapeutic relationship and enhances the likeli¬
hood of being able to help clients help themselves (Reid, 1998). Being non¬
judgmental and open-minded also suggests and requires respectfulness vis-a-vis
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 25

the client, as well as a stance of egalitarianism that eliminates power differen¬

tials between client and provider (Land, 1998).
As reflected in the need for flexibility, counselors and therapists need to be
able to deal with unknowns and to be willing to take risks and explore new
ground. Being able to deal with ambiguity is a critical skill of every counselor
(Kottler and Brown, 1992). All therapists have to be capable of epistemological
feeling (Knobel, 1990, p. 61), that is, they must have the ability to listen em-
pathically and to alter their assessments of a client’s situation flexibly and ap¬
propriately in changing contexts (Cormier and Cormier, 1998). Unwillingness
to follow intuitions can result in leaving facets of the client undiscovered that
might otherwise prove crucial to growth and change. In the therapy setting,
risk-taking has to be weighed against the possible consequences of making a
mistake, but it is rare that one failed or inappropriate treatment intervention
derails the entire therapeutic process. Indeed, some clinicians believe that the
occasional empathic failure of the therapist is crucial to successful treatment
(Kohut, 1984; Wolmark and Sweezy, 1998). Only repeated failures are likely to
have an impact, not one unfortunate choice of wording or behavior. It is often
preferable for the counselor to follow an intuition and risk a new intervention
that seems right than to adhere rigidly to one that has already proven less than
successful.
In facilitating the therapeutic process, it is important that counselors allow
their own selves to come through, to be authentic (Knobel, 1990), and genuine
(Egan, 1994). It is quite impossible for clinicians to deny who they really are out¬
side of the therapy room, as personality can neither be hidden nor camouflaged
(Chrzanowski, 1989). The clinician must recognize, however, that authenticity
does not equal self-disclosure. The therapy is there for the client; it is not in¬
tended to give the therapist the opportunity to self-disclose or deal with per¬
sonal psychological or emotional issues. All therapists and counselors have a cer¬
tain interpersonal style: Some are extroverted and active; others are introverted
and observing. This general pattern shows through in the types of interven¬
tions a clinician chooses (cf., Keinan, Almagor, and Ben-Porath, 1989; Kolevzon,
Sowers-Hoag, and Hoffman, 1989), and finding a way of doing therapy that fits
with the clinicians general style of being and life values is critical (Dorfman,
1998). Only if the style fits the clinician will she or he be able to muster the en¬
thusiasm that is so crucial to the treatment of any client. It is impossible for
counselors to deny who they are in the way they greet their clients, sit in the
room, and interact throughout the session. Being themselves expresses their hu¬
manity and allows them to extend common human courtesies to their clients.
Adapting ones therapeutic style and technique to personal traits is not the
same as abandoning the therapeutic neutrality. It is still important to be non-
judgmental and not to impose certain opinions or outcomes on a client (Kot¬
tler and Brown, 1992). However, a clinician takes neutrality too far if it translates
26 CHAPTER ONE

into sterile and impersonal ways of relating to clients. Even psychoanalytic

therapists have come to recognize that remaining anonymous does not mean
being nonresponsive (cf., Basch, 1980; Wolf, 1988) or having no personality. It
merely means maintaining clear boundaries and retaining the focus of the ses¬
sion on the client, not the therapist (Brems, 1999; Morrison, 1995). In this re¬
gard, immediate needs of the mental-health-care provider are kept out of the
therapy session. For example, if clinicians are hungry or upset, they delay grati¬
fication of these needs and feelings while with the client (Kottler and Brown,
1992). This may be one of the greatest challenges for the new practitioner, but
becomes second nature as time wears on. It also makes self-care outside of the
therapy room an even more important component of therapists’ lives so as not
to become a human being who is full of denial of personal needs and feelings.
Another important personal characteristic of the successful counselor is
empathy. Each therapist strives to understand how a client feels in a given sit¬
uation, given that clients specific and unique experiences, history, and back¬
ground (cf., Kohut, 1984; Shulman, 1988). Empathy, thus defined, requires the
therapist to listen carefully and to hear or see not only the overt content of what
is being expressed either verbally or behaviorally, but also to listen to the latent
message that is contained within the clients expression. Such empathy, also
termed vicarious introspection (Kohut and Wolf, 1978), is more than the warm,
fuzzy feeling of caring; it is an artful and scientific approach to better under¬
standing. Empathy is incomplete if it ends with the internal or private under¬
standing of the client by the therapist. Empathy only serves a positive therapeu¬
tic purpose if the therapist is able to communicate understanding back to the
person (Brems, 1999). Once counselors have listened carefully and believe they
have empathically understood the communication of the client, this under¬
standing is communicated back to the client. Only when the client receives the
message of understanding and feels the therapist s empathic concern is the inter¬
personal cycle of empathy complete (cf., Barrett-Lennard, 1981; Brems, 1989).
The ability to enter intimate and caring relationships is a prerequisite that
almost needs no mention. Clinicians clearly have to be able to enter into a mean¬
ingful dialogue with other human beings, need to be able to exude warmth and
caring, must not fear rejection or closeness, and must be open to the humanity
in all people (Cormier and Cormier, 1998). A clinician who is aloof or excessively
distancing will likely have some trouble developing therapeutic rapport. As
with genuineness and authenticity, the clinician needs to walk a fine line. So¬
cial relationships with clients are inappropriate, as are intimate or sexual ones.
Interpersonal warmth and caring must be expressed in a therapeutically ap¬
propriate manner to help the client feel cared for without violating treatment
boundaries.
Finally, there is the issue of the mental health of the clinician. By defini¬
tion, mentally healthy individuals have many of the traits that make a human
being successful in the helping professions. Mentally healthy people are ca-
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 27

pable of empathic attunement, have the wish and the ability to understand the
needs of others, understand their own needs, are capable of delaying their own
needs to meet the needs of others, are realistically self-confident with a clear
acceptance of personal flaws and shortcomings, have little fear of rejection or
humiliation, possess a certain amount of creativity, have a sense of humor, and
are wise (Rowe and Maclsaac, 1986). The latter three concepts beg some defi¬
nition. Creativity refers to a persons ability to derive pleasure from problem
solving. This pleasure in coming up with solutions to tough situations and cir¬
cumstances is reinforcing for clinicians and continues to propel them toward
finding options and alternatives, both in their own lives and in the lives of cli¬
ents. Creativity is one of the most important traits in successfully dealing with
challenges and crises of clients and of daily living. A sense of humor is defined
as the ability to laugh at oneself. It excludes biting sarcasm or vicious irony, in¬
stead referring to the capacity to make light of past failures and minor imper¬
fections, and not to take life or oneself too seriously. Finally, wisdom is charac¬
terized by the acceptance of personal limitations and frailties. Wise persons can
forgive mistakes and lack of ability, accepting self and others fully. Wisdom dic¬
tates that parents, teachers, and clinicians can be forgiven and accepted even if
they have made mistakes in the past and can be respected and cared for never¬
theless. True wisdom is achieved if this capacity is present in relation to others
and the self.
In summary, many personal traits can greatly facilitate the therapeutic or
counseling process through their mere presence. They are the traits graduate-
level instructors look for in their new students as they are often the very things
that will differentiate the successful from the unsuccessful therapist. Although
all of these traits can be fostered and developed, their preexistence is a great
asset, their absence often a warning sign. Absence of these traits generally re¬
quires that the student take some personal time to develop and foster them.
Often this can involve personal therapy or counseling; it always involves en¬
gaging in the self-care skills that are outlined in a later chapter (and also in
Brems, 2000). Ultimately, management of these personal traits determines not
only the success of the clinician with clients, but also the clinicians ability to
sustain his or her own mental health throughout a career.

Hindering Traits of Mental-Health-Care Providers

The presence of traits that tend to be less than therapeutic is often more prob¬
lematic than the absence of some of the positive traits mentioned. Given the
fact that these traits share some of the same qualities, that is, they are preexist¬
ing, ingrained, and habitually present in the individual, the potential for nega¬
tive influence is great. Elimination of negative traits will have to be addressed
by as many avenues as possible, including through self-care, personal counsel¬
ing or therapy, and careful supervision. It is impossible to mention all possibly
28 CHAPTER ONE

hindering personal traits, just as it was impossible to identify all facilitating traits.
It is important to note that in the discussion of positive traits, the absence of
any of the positive traits by definition implies the presence of a hindering trait.
Thus, the mere opposites of positive traits—for example, absence of self-es¬
teem, intolerance, lack of flexibility—will not be addressed again here. What
follows is a discussion of a few additional personal traits that can interfere with
therapeutic process or rapport.
One important trait that can interfere with good mental-health service de¬
livery is fear of failure. Fear of failure can lead clinicians to take the safe ap¬
proach, never taking risks or following intuitions, and may result in allowing the
client to “run the show.” Fear of failure can force the client into false mental
health as the client will pick up on the clinician’s great need for the client to im¬
prove. This flight into health has been talked about in the psychoanalytic and
psychodynamic literature (for example, Kohut, 1984; Wolf, 1988), but is not
often mentioned in this context.
Another fear that gets in the way of good therapeutic work is the fear of
reaching out to other resources. Such clinicians believe that they have to solve
all the problems in the world alone and should never have to rely on other re¬
sources in helping a client heal or grow. The ensuing lack of referral for addi¬
tional assistance can leave the client vulnerable and can lead to inappropriate
treatment. Failing to refer a client with a possible medical condition is only one
such example. Less egregious examples of a clinicians unwillingness to draw on
other resources include the inability to refer to support groups or to ask for
help from a consultant or supervisor, and similar omissions. This fear can be re¬
lated to arrogance in the clinician, but this is not always the case. Sometimes
mental-health-care providers who fear reaching out are just shy and have the
idea that they ought to know everything. More devastating are those clinicians
who do not reach out because they think they do know all the answers. Their
overcertainty leads them to make diagnoses and treatment plans that are less
than optimal, and may also lead to misinterpretations and misunderstandings.
Clearly, counseling does not tend to be successful when an overly certain clin¬
ician fails to seek input and moves ahead with a chosen treatment even in the
face of evidence that it is not working.
A third fear that can get in the clinicians way is the fear of newness. These
are the clinicians who do the same thing day in and day out; they use the
same intervention with each client, whether it is relevant and effective or not.
Often these clinicians are afraid to try anything new; sometimes they are un¬
willing. When they are unwilling, their fear of the new is often coupled with ar¬
rogance or overcertainty. Sometimes these clinicians are merely bound to the
tradition in which they were trained. They adhere strictly to the principles
of their former supervisors or the books they studied. They do not realize that
the field advances, new developments can help speed up treatment, or their
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 29

■personal style may be better accommodated by an alternative approach. Over¬

adherence to tradition is highly problematic and can make the clinician rigid
and inflexible.
Also problematic can be needs of clinicians that are carried into the ther¬
apy or counseling setting. Such needs include the need to be admired, the need
to be accepted, the need for respect, and the need for awe. Mental-health-care
providers with these needs will feel dissatisfied if their clients cannot provide
admiring or sustaining responses, which is more likely than not. Since clients
come to treatment to work on emotional problems, they are highly unlikely to
want to provide positive feedback to their clinician, nor should they ever be ex¬
pected to do so. The clinician who needs to have these needs met in the coun¬
seling setting is prone to burnout and dissatisfaction. The counselor who has
these needs may well perceive the client in a negative light when no admiration
is forthcoming. Coming to treatment with needs is a setup for clinicians; coun¬
selors and therapists need to make sure first that all their needs are healthy and
developmentally appropriate; and second that their needs are met outside of
the therapy room.
Another hindering set of traits is the lack of a sense of humor or lightness,
and the inability to be anything but severe and serious. Taking everything overly
seriously and never being able to laugh with a client can create a very heavy or
burdening environment. Sometimes the best thing to do in a crisis is to diffuse
some of the seriousness with lightness, to allow some of the sorrow to be lifted
by optimism. This is not to say that clinicians have license to make light of their
clients’ concerns. It merely suggests that the inability to let up can become quite
burdening and depressing.
A final hindering trait that will be mentioned here is actually a collection
of traits. It is the clinicians inability to access a certain aspect of the human ex¬
perience either in the self or in the client. One way this problem may mani¬
fest is as an inability to feel—either in the form of being completely unaware
of personal emotions or in the form of not being able to tolerate affect in
clients. Similarly, but in a different realm of human experience, it is problem¬
atic if a clinician is cut off from cognitions. This may mean the clinician is un¬
aware of personal cognitive process or may manifest as an inability to under¬
stand the thought process of clients, perhaps because of an overemphasis on
emotion—the clinician whose answer to everything is to explore how the
client feels.
The third realm of human experience refers to the clinicians behavior.
Unawareness of personal behavior could mean being significantly overweight
and not recognizing what this may communicate to the client about per¬
sonal impulse control. Using drugs or alcohol or engaging in other detrimental
behaviors would also suggest that the clinician is unable to exert proper self¬
regulation in the realm of behavior. Clinicians unable to recognize the need for
30 CHAPTER ONE

self-regulation in their own lives may likewise be unable to identify problem

behaviors in clients and may fail to recognize where proper intervention needs
to take place.
The final example of this type of negative trait is if the clinicians blind spot
is in the area of relationships. A clinician who cannot access personal needs for
relatedness and human contact (that is, one who is truly schizoid or avoidant)
will have a hard time making contact with a client in any realm (affect, thought,
or behavior). Similarly, this clinician may not recognize a client s devastating re¬
lationship patterns and may intervene in ways that lead to the reinforcement
of unhealthy relatedness patterns.
All hindering traits, whether the ones noted above, or others, will manifest
in the client-clinician relationship in some form. One common way in which the
literature has dealt with hindering traits is through the discussion of counter¬
transference, since that is the way in which hindering traits most commonly re¬
veal themselves. Following is a discussion of countertransference and how to
deal with it.

Countertransference Issues
It is generally agreed that countertransference enters therapy or counseling
through lack of self-awareness and usually presupposes that the clinician is not
cognizant of the fact that the therapeutic process or rapport is beginning to be
influenced by his or her personal beliefs, needs, traits, and attitudes (Holmquist
and Armehus, 1996). Countertransference is most traditionally defined as a
therapists response to a client that is based upon the therapists unconscious in
general, and unconscious anxieties and conflicts in particular (cf., Freud, 1949,
1959; Webb, 1989). However, this definition is very global and does not differen¬
tiate the different manifestations countertransference can take in actual treat¬
ment. Hence, further definition has resulted in the identification of four types of
countertransferences: issue-specific, stimulus-specific, trait-specific, and client-
specific countertransference (Brems, 1994). The first three types tend to be dis¬
ruptive to treatment and always arise out of a lack of self-awareness. The fourth
type of countertransference does not fit the traditional criteria of counter¬
transference in that it can actually serve a therapeutic purpose and generally
arises because the clinician is keenly self-aware and introspective. It is often
discussed in the context of countertransference, but not always with the rec¬
ognition that it has an appropriate and rightful place in counseling and therapy
and serves a useful purpose.
A few red flags that negative countertransference may have been stimu¬
lated in a client-clinician relationship are shown in Table 1-4 and should alert
the clinician to engage in self-exploration or to seek supervision.
 Red Flags for Issue-Specific, Trait-Specific,
or Stimulus-Specific Countertransference

Possible Types of
Countertransference
That Are Being
Red Flag Stimulated

Avoidance of certain topics Issue-specific

Negative reactions to certain topics Issue-specific

Heightened emotionality around certain topics Issue-specific

Tendency toward overreaction to certain topics Issue-specific

Stereotyped or predictable reaction to certain topics Issue-specific, trait-specific

Avoidance of certain types of clients Stimulus-specific

Rejection of certain types of clients Stimulus-specific

Negative reactions to certain types of clients Stimulus-specific

Heightened emotionality around certain types of clients Stimulus-specific

Tendency toward overreaction to certain types of clients Stimulus-specific

Stereotyped or predictable reaction to certain types Stimulus-specific,

of clients trait-specific

Overidentification with certain types of clients Stimulus-specific,

issue-specific

Sexual or romantic feelings for certain types of clients Stimulus-specific,

trait-specific

Sexual or romantic feelings for a particular client Issue-specific, stimulus-

specific, trait-specific

Overprotectiveness with certain types of clients Stimulus-specific, trait-

specific

Overprotectiveness with a particular client Issue-specific, stimulus-

specific, trait-specific

Desire for a social relationship with certain types of clients Stimulus-specific, trait-
specific

Desire for a social relationship with a particular client Issue-specific, stimulus-

specific, trait-specific

Rejection of a particular client Issue-specific, stimulus-

specific, trait-specific

Seeking of or need for approval or admiration from clients Trait-specific

Advice-giving or directing clients Trait-specific

Encouragement of dependence Trait-specific

Paternalism or fostering of inequality between client Trait-specific

and clinician
32 CHAPTER ONE

Issue-Specific Countertransference
Issue-specific countertransference arises as a reaction resulting from the stimu¬
lation of unexplored (unaware or unconscious) aspects of the clinician in re¬
sponse to specific behaviors, feelings, and needs expressed by a client. In other
words, the clinician’s reactions to a clients issues are flavored by personal needs,
attitudes, values, beliefs, or traits that the clinician is generally not aware of.
This reaction is often referred to as unresolved conflicts of the clinician (for ex¬
ample, Corey, Corey, and Callanan, 1998). For instance, a therapist who has
anxieties about sexuality may be particularly threatened and may respond nega¬
tively to the discussion of sexual issues by a young client, especially if that client
has learned and incorporated seductive behaviors. Another therapist who is
free of unconscious sexual values or beliefs may respond to the same client in
an entirely different manner. Such clinicians may be entirely capable of treat¬
ing other clients, that is, those clients who do not present with issues that tap into
a clinicians own personal (unconscious) needs, beliefs, and attitudes. A clini¬
cian’s success with some clients does not justify failure to resolve unexplored ar¬
eas of self that can get in the way of counseling or therapy because of their like¬
lihood to pop up in a countertransferential manner. The crux of this type of
countertransference is the coincidental and unfortunate coming together of a
counselor’s and client’s issues that are incompatible, too similar, or too threat¬
ening. When mental-health-care providers begin to realize that certain topics
or issues stimulate heightened feelings or specific reactions on their part, it be¬
hooves them to seek some guidance in trying to figure out what is creating their
excessive or inappropriate response. Self-exploration and consultation are help¬
ful avenues to pursue in this regard.

Stimulus-Specific Countertransference
A second type of countertransference has been labeled stimulus-specific coun¬
tertransference. In this case, the reaction is not stimulated by a client’s expressed
therapy issues, but rather arises in response to an external or personality fea¬
ture in the client that stimulates material in the clinician that is irrelevant to the
client’s presenting concerns. In fact, any individual, client or not, would stimu¬
late this (over)reaction in the mental-health-care provider. For instance, clini¬
cians with yet-to-be-explored issues around sibling rivalry with a brother may
respond inappropriately or inexplicably to all male clients who remind them of
this brother. Stimulus-specific countertransference reactions are usually to
blame if a clinician (or anyone for that matter) reacts inappropriately to all cli¬
ents or human beings who share a particular physical, psychological, or emo¬
tional trait (such as excessive weight, a particular skin color, or a stern de¬
meanor) because that stimulus taps into (unconscious) emotions or beliefs in
the clinician that have not been adequately explored. The crux of this counter¬
transference is the therapist’s unconscious and immediate reaction to an exter-
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 33

Hal stimulus that is independent of the client s treatment needs or presenting

concerns.

Trait-Specific Countertransference
Trait-specific countertransference is even more global and has also been re¬
ferred to as a clinicians “habitual modes of relating” (Sandler, 1975, p. 415, as
quoted in Bernstein and Glenn, 1988, p. 226), or the care providers “expres¬
sion of character traits” (Lilleskov, 1971, p. 404, as quoted in Bernstein and
Glenn, 1988, p. 226). This type of countertransference reaction implies that
clinicians respond to clients as they tend to respond to anyone at any time in
their life. For instance, a therapist with rigid morals, who tends to be conde¬
scending and judgmental in general, will bring this attitude into the treatment
room. Clearly, such an habitual way of relating is dangerous as it not only is au¬
tomatic and unconscious, but will potentially and profoundly influence the
clinicians therapeutic work with any client, regardless of issues presented or
stimuli expressed. Trait-specific countertransferences not uncommonly arise
out of the various motivations of clinicians to seek a career in mental health
(see above). For example, if a clinician is motivated by the need to control and
influence, a likely trait-specific countertransference is a controlling and advice¬
giving therapeutic stance. This clinician is likely to attempt to exert control in
all relationships, including those with significant others, friends, and clients. A
clinician who is motivated by the desire to help, on the other hand, will likely ev¬
idence a caregiver, enabler, or rescuer countertransference, again generally,
not only in relationships with clients, but in most if not all interpersonal settings.
The crux of this type of countertransference is the mental-health-care provid¬
ers habit-driven, characteristic manner of relating to all people in many if not
all contexts, including the therapy or counseling setting. The clinicians lack of
awareness about this interpersonal style and habitual self-expression allows the
treatment to become distorted and driven by clinician, not client, needs.

Client-Specific Countertransference
Client-specific countertransference is a reaction in the clinician to a client that
occurs only with that client. In fact, if the clinician begins to explore the client s
relationships, it often becomes evident that the client elicits this or a similar
reaction in most, if not all, adult relationships. The reason this type of counter¬
transference is included as a countertransference at all is the reality that in the
past any emotional reaction on the part of a clinician was considered unusual
(even inappropriate). It has since been recognized that reactions in clinicians
to clients can be useful therapeutic tools as long as the clinician is aware of the
reaction and can understand it as being specific to the client. It is critical for
clinicians to explore whether their reaction is genuinely stimulated by a pattern
in the client—or by one of the three prior types of countertransferences dis¬
cussed thus far. The best way to double-check this is to carefully explore what
34 CHAPTER ONE

Skill Development Recommendations

Recommendation 1-3 Using Table 1-3, evaluate yourself on each of the listed
traits, thinking about feedback you have received about yourself in a variety of
interpersonal settings. Also, interview someone close to you about his or her
perceptions of you with regard to each of these traits. Pick this person carefully
for their honesty, good will, and knowledge of you.

types of reactions the client tends to elicit in others. If a similar pattern emerges,
most likely a true client-specific countertransference is taking place. If the
client reports no such reactions in others, the clinician needs to explore whether
a countertransference based on issue, trait, or stimulus better explains the reac¬
tion. If this is the case, the clinician will most likely note a similar reaction with
other clients; in other words, the pattern follows the clinician, not the client.
To give an example of a client-specific countertransference, a very oppo¬
sitional and demanding client with poor self-esteem and strong attention¬
seeking behavior may overwhelm and alienate adults after prolonged contact.
The mental-health-care provider may experience the same frustration in ses¬
sions that others encounter with the client outside of counseling. Hence, this
reaction is not due to the clinician’s lack of self-awareness, but rather is specific
to the clients behavior. The crux of this countertransference is the client’s elic¬
iting of a consistent (for example, negative or protective) response from the en¬
vironment, shared by the clinician.
Client-specific countertransference, unlike the other types, provides the
self-aware clinician with added insight and empathy about the client. Such a
countertransference reaction can be used therapeutically and purposefully with
the client. It provides information about the client and can provide excellent
feedback about the client’s impact on the environment, as well as providing in¬
formation about why this client elicits a similar response in so many contexts.
It provides insight regarding target behaviors of the client that may need to be
modified quickly to help the client improve interpersonal relationships.

The Next Step: Necessary Skills

for Mental-Health Practice

This chapter has outlined the great importance of taking stock of personal is¬
sues that may enter into the decision to make a career in the mental-health field
and that may influence actual professional practice once a clinician works with
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 35

clients. Self-awareness clearly is the key to success. It is therefore critical that

clinicians learn self-awareness skills during their graduate education. Self-
awareness skills can be conceptualized rather broadly as including

• individual self-awareness (addressing issues such as personal traits, val¬

ues, attitudes, and beliefs)
• interpersonal self-awareness (addressing issues such as needs in relation¬
ships and effects on others)
• cultural self-awareness (addressing issues such as prejudice, bias, and
stereotyping)
• physical self-awareness (addressing issues such as body language, non¬
verbal communication, and voice quality)
• professional self-awareness (addressing issues such as learning skills and
strategies, choosing skills and strategies, and individualizing counseling or
therapy to client needs)

Self-awareness skills defined in such a manner comprise the full spectrum

of skills that are the basis of counseling and therapy. They range from the per¬
sonal to the professional and include not only personal self-exploration, but also
professional development and learning. Even the necessary communication
and therapeutic or counseling skills that will ensure success with a wide range of
clients can be conceptualized as being part of developing self-awareness. The
remainder of this book concerns itself with assisting students in the mental-
health field to acquire self-awareness skills in all personal and professional ar¬
eas relevant to the practice of counseling and therapy.
Chapter One served to set the reader on the path of personal self-explora¬
tion by asking her or him to take a look at individual traits and countertrans¬
ferences. Chapter Two continues the work on the development of individual
self-awareness skills, but also addresses interpersonal and cultural self-aware¬
ness. In that context, it will raise issues such as values clarification and develop¬
ment of cultural competence. Chapter Three will address preventive self-care,
an important aspect of individual self-awareness training and an excellent
means of impairment prevention.
The remainder of the book will deal with physical and professional self-
awareness. Part Two begins this process through exploration of physical self-
awareness and will be devoted to communications skills. These chapters will
address issues such as attending and listening skills; nonverbal communication;
enhancing communication and data gathering through the skilled use of ques¬
tions; and facilitating self-disclosure through encouragers, restatements, para¬
phrases, reflections, and summarization. Part Two ends with a discussion of
empathy, the bridge between simple communication skills and skills that en¬
courage growth and healing.
The third part of the book concludes the professional self-awareness de¬
velopment process by concerning itself with the creation of insight or cognitive
 Individual
Self-Awareness

/
\

V_J
FIGURE 1-1
Diagram of Therapeutic Competence
 TRAITS OF SUCCESSFUL THERAPISTS AND COUNSELORS 37

.self-awareness in clients. Topics will include an overview of types of cognitive

interventions to use and a variety of strategies ranging from simple imparting
of information to complex cognitive interventions that require great cognitive
flexibility on the part of the clinician.
The fourth part of the book, continuing the development of professional
self-awareness, will deal with facilitating affective self-awareness in clients.
These chapters will present issues such as recognizing what level of affective
intervention is needed, empathy as a process and its specific application, and a
variety of exercises that can be used with clients to help them work with feel¬
ings, moods, and emotions. Before moving on to the next chapter, it is recom¬
mended that readers thoroughly review and engage in the Skill Development
Recommendations.
In summary, therapeutic competence is a combination of self-awareness,
knowledge, and application of skills. Self-awareness reflects the personal aspect
the clinician brings to the therapeutic encounter. Knowledge is comprised of
the wealth of information the mental-health-care provider accumulates through
education and training. Application of skills refers to the translation of aware¬
ness and knowledge into action. All three aspects of therapeutic compe¬
tence have to be attended to, for successful counseling or therapy to take place.
Ignoring the personal aspects by not engaging in self-exploration and intro¬
spection can allow knowledge to be undermined by automatic reactions that
make the application of information less than skillful. On the other hand, self-
awareness alone does not suffice to make a good clinician. Knowledge and in¬
formation are essential for the mental-health-care provider to know what to do
when and why. Practicing interventions and strategies contributes to skill de¬
velopment. However, the simple carrying-out of skills in a mechanical or unin¬
formed way, that is, in a manner that is informed neither by self-awareness nor
knowledge, will leave the client feeling less than cared for. Competence thus
defined can be diagrammed as shown in Figure 1-1 and represents the foun¬
dation of this text.
Self-Awareness
Skills

Self-knowledge is an anchor that makes

unpredictability tolerable.
Deepak Chopra

Work with clients in counseling or therapy can be enjoyable and rewarding as

well as taxing and exhausting. This chapter explores how counselors and ther¬
apists can develop self-exploration and introspection skills that can facilitate
good therapeutic rapport and clear understanding of the process that unfolds
between client and clinician. First, attention is focused on exploring values that
clinicians endorse personally and professionally, to show how values enter
treatment and the therapeutic relationship. Awareness of personal values is
crucial to recognizing when they may distort—or enhance—what transpires
between client and clinician. Attention then turns to an exploration of cul¬
tural sensitivity and competence. Counselors and therapists need to have
knowledge about, awareness of, and skills for culturally competent and sensi¬
tive practice, given that in today’s world many clients differ in background from
their mental-health-care provider. These differences are not only ethnic or
racial, but also include a diversity of other cultural backgrounds that will be
dealt with in this discussion. Once values have been clarified and cultural com¬
petence has been developed, mental-health-care providers are in a much bet¬
ter place to begin work with clients in a manner less likely to reflect biases or
countertransferences.
Developing individual and interpersonal self-awareness is not an easy task.
It requires openness and willingness to find out less than flattering facts about
the self, both personally and in relationships. Creating self-awareness can be un¬
comfortable, can result in self-consciousness and self-doubt, and may lead to
inhibition and pain (Sommers-Flanagan and Sommers-Flanagan, 1999). Fortu¬
nately, these negative effects of self-exploration are temporary and lead to posi¬
tive outcomes that will benefit both clinician and client. As pointed out in Chap-

38
 SELF-AWARENESS SKILLS 39

ter One, self-awareness needs to be sought in at least five areas: individual, in¬
terpersonal, cultural, physical, and professional. The issues relevant to individ¬
ual, interpersonal, and cultural functioning usually involve preexisting clinician
traits. As defined in Chapter One, traits preexist, while skills need to be devel¬
oped. As such, the self-awareness work in these three realms involves explo¬
ration of existing counselor or therapist characteristics, a process that has been
referred to as values clarification. The issues relevant to physical and profes¬
sional self-awareness generally involve skills that have to do with communica¬
tion (verbal and nonverbal) and intervention strategies in counseling and ther¬
apy. As such, they require not so much a process of clarification as of learning
(of course all learning also involves some component of clarification or explo¬
ration). This chapter concerns itself with exploration of traits, though it will also
make some suggestions for new learning, especially in the realm of cultural
self-awareness.

Values Clarification

Ethical, professional, moral, and legal behavior presupposes that clinicians are
individually and interpersonally self-aware, knowledgeable, open-minded, and
well informed. “Counselors are required to distinguish their personal moral
codes from and reconcile them with the professions values to behave in an ethi¬
cal manner” (Cottone and Tarvydas, 1998, p. 123). Being able to do so clearly
hinges on exploring and identifying personal values that underlie ones moral
beliefs. Perhaps some definitions are in order first. Morals refer to an individual s
beliefs about what is good or bad behavior. They are standards used as guides
for conduct, especially in social contexts (Steinman, Richardson, and McEnroe,
1998). They reflect the individuals “perspectives of right and proper conduct”
(Corey, Corey, and Callanan, 1998, p. 3), and are usually grounded in the stan¬
dards of a broader cultural group (including religious groups). Values, on the
other hand, are less social, and more individually formed and based. They are
the “beliefs and attitudes that provide direction in everyday living” (Corey,
Corey, and Callanan, 1998, p. 3), and reflect priority systems people use to
guide their personal decision making and choices (Steinman, Richardson, and
McEnroe, 1998). Ethics reflect “beliefs . . . about what constitutes right con¬
duct” (Corey, Corey, and Callanan, 1998, p. 3), based on an understanding of a
set of guidelines or an ethical code, often developed by a professional group to
guide professional behavior. A code of ethics judges human actions based on a
hierarchy of values that makes the evaluation of behavioral choices supposedly
objective and rational (as opposed to morals, which are personal and less than
objective or rational; Cottone and Tarvydas, 1998). Laws arise from the morals
of a social system or cultural group; professionalism reflects right conduct
40 CHAPTER TWO

given a professions requirements and parameters. Thus, values are personally,

morals are socially, laws are societally, and ethics are professionally based. Val¬
ues, morals, ethics, laws, and professionalism interact and at times can require
the same outcome or render the same evaluation. However, behavior can also
be ethical or legal yet unprofessional (for example, lateness to sessions by a
clinician is unprofessional but not unethical or illegal); legal but not ethical (ac¬
cepting large gifts from clients may be legal, but it is neither ethical nor pro¬
fessional); rooted in personal values or social mores, but not ethical (creating
client dependency on the clinician may be personally preferred by the clini¬
cian, perhaps even condoned by the culture, but is not ethical); and so forth.
To make ethical, legal, and professional decisions, counselors and thera¬
pists not only have to be aware of and knowledgeable about the codes of con¬
duct that regulate their profession, but also about their personal values and so¬
cially based morals. A thorough discussion of the ethical standards developed
by the various associations of the mental-health professions, such as the Na¬
tional Association of Social Workers, the American Psychological Association,
and the American Counseling Association, is beyond the scope of this book. This
issue has been dealt with in a variety of texts, including those by Anderson
(1996); Canter, Bennett, Jones, and Nagy (1994); Corey, Corey, and Callanan
(1998); Cottone and Tarvydas (1998); Herlihy and Corey (1992, 1996); Stein-
man, Richardson, and McEnroe (1998); and Swenson (1997); and through the
ethical codes established by the relevant professional associations (American
Psychological Association [APA, 1992]; National Association of Social Workers
[NASW, 1993]; American Counseling Association [ACA, 1995]). What will be
provided below is a general review of the moral principles that underlie most
if not all ethical codes, and a discussion of how personal values relate to these
issues. This is followed by suggestions on how clinicians can gain the necessary
individual and interpersonal self-awareness to behave ethically, professionally,
and legally.

Mandatory Versus Aspirational Ethics

Many ethical guidelines are actually documents that contain within them two
sets of ethics: mandatory ethics and aspirational ethics. Mandatory ethics are
much easier to deal with as they are usually relatively clear in their application,
strictly enforced, have clear consequences for violation, and are written in
such a way that all mental-health-care providers for whom the ethical guide¬
lines are written must comply with them. Mandatory ethics are often called
a standard of practice; they may be incorporated into a professions ethical
guidelines or may be presented in a separate document. An example oi a man¬
datory ethic that cuts across all ethical guidelines of the mental-health pro¬
fessions is the prohibition against sexual relationships with clients. This is a
 SELF-AWARENESS SKILLS 41

clear guideline with no gray area: Sex with current clients is forbidden and
will carry consequences for the provider who violates this mandatory ethic.
Aspirational ethics represent the ideal professional behavior. They describe
optimal practice, the best possible standard for behavior among the mental-
health-care providers within a given profession. These ethics are not man¬
datory and have many more gray areas. Violation or noncompliance may be
more difficult to establish, and because of this difficulty enforcement is not a
given. An example of an aspirational ethic that is found in all ethical guidelines
for mental-health-care providers is the provision of pro bono services. All pro¬
fessions appear to suggest that their providers provide some of their service on
a sliding-fee scale or at no cost to needy clients. This aspirational ethic is an
ideal, a standard that is difficult to enforce. A provider who has not or is not
currently providing pro bono service is generally not vulnerable to a charge of
ethical violation.
If personal values lead a practitioner to violate a standard of practice
(mandatory ethics), the consequences are generally clear and enforced. The vio¬
lation of aspirational ethics, on the other hand, bearing no clear and direct con¬
sequences in many instances (though they will in some), is thus often left to the
individual practitioner to determine and rectify. It is in the area of aspirational
ethics that personal values and morals enter most profoundly. Only excellent
self-monitoring and self-awareness may keep clinicians on the path of remain¬
ing true to the aspirational ethics of the profession. For example, clinicians may
need to evaluate regularly their purposes in keeping some clients in treatment
for longer periods than others. Should they realize that clients who pay more
or who have better third-party reimbursement tend to have more sessions, it
will strictly be clinicians’ personal values that will steer them back on the cor¬
rect path. The decision making process regarding ethical behavior (mandatory
and aspirational) is based on six moral principles that become most useful in
evaluating gray areas of conduct. They are autonomy, beneficence, nonmalefi¬
cence, justice, fidelity, and veracity (the latter two are sometimes collapsed into
one and referred to simply as fidelity).
Autonomy refers to the clinicians willingness to honor the right of individ¬
uals to make their own decisions. This principle is occasionally translated as self-
determination, individualism, or independence (for example, Corey, Corey, and
Callanan, 1998). However, the better understanding truly has to do with free
choice, the right to decide ones own fate, and to choose ones own life direc¬
tion. This right suggests that independence or individualism does not have to
be the choice, that is, this definition is more culturally sensitive in that it allows
clients the autonomy to decide not to be autonomous. The main issue from the
clinicians perspective about autonomy as an ethical principle is that the client
has the right to choose and the clinician does not make determinations for the
client about the direction of treatment or the nature of the solutions.
42 CHAPTER TWO

Beneficence refers to the commitment to do good to others. This principle

speaks to the promotion of clients’ welfare, dignity, and respect. It is concerned
with assuring that the goals set in treatment, the strategies chosen for interven¬
tion, and the outcomes achieved are for the good of the client. This is a highly
individualized principle in that what is for the good of one client may not be
for the good of another. One example of this specificity or tailoring of treat¬
ment to the welfare of the client occurred in Alaska several years ago. As part
of a masters thesis, a trainee set out to teach assertiveness skills in the schools
in Anchorage. Assertiveness training is generally thought of as being good for
clients; it reflects a value that is highly regarded in Western society. However,
Anchorage has a diverse ethnic population, and Alaska Native culture has a dif¬
ferent standard for assertiveness, especially in the home. The Alaska Native
students exposed to assertiveness training through this, trainee’s program began
reporting greater trouble at home and their parents were not pleased. The
skills taught, which truly were for the good of the European American and Af¬
rican American students in the classroom, were not for the good of the Alaska
Native pupils. Thus, beneficence has to be individually determined and as¬
sessed within the context of each client.
Nonmaleficence refers to the understanding that the utmost concern of the
mental-health-care provider has to be to do no harm. Clearly related to benefi¬
cence, it nevertheless deserves separate mention and definition. Doing no harm
refers to intentional or purposeful behaviors and interventions as well as un¬
intentional ones. Nonmaleficence implies that clinicians need to be respectful
of their clients, need to consider cultural differences and expectations, need to
take into account individual differences and needs, and need to tailor treatment
idiosyncratically to the unique presentation of each client. One example of an
unintentional, thoughtless violation of the principle of nonmaleficence is the
inappropriate (less than sensitive) use of diagnostic labels. Diagnoses can pro¬
foundly affect clients’ perception of self and may label them inappropriately for
many years to come. The misuse of diagnostic labels has been pointed out re¬
peatedly in the literature, especially with regard to inappropriate diagnostic la¬
beling of non-White ethnic groups (see Brems, 1999).
Justice refers to the fair and equal treatment of and access to services for
all clients. Also called distributional justice, this principle requires nondiscrim¬
ination in service delivery, fairness in eligibility criteria, and equal distribution
of resources across actual and potential clientele. It is this principle that drives
consideration in professional codes for pro bono work with needy clients who
would otherwise not be able to receive services. It is also this principle that un¬
derlies demands for flexible clinic hours and interventions tailored to the indi¬
vidual, social, socioeconomic, and cultural circumstances of all clients. Equal
access, equal treatment, and fairness are the essence of this principle.
Fidelity refers to honesty, loyalty, and the commitment to keep promises.
According to this principle, the work of clinician and client represents a social
 SELF-AWARENESS SKILLS 43

•contract that must be honored by the clinician. The counselor must uphold all
promises made within this contract and must honor all commitments. Much of
what is promised in the clinician-client relationship is spelled out in the in¬
formed consent signed by the client at the beginning of treatment. Given that
this informed consent is a binding social contract, it is the clinician’s responsi¬
bility to follow through on any promises and commitments outlined in this docu¬
ment. Fidelity most specifically refers to aspects of the informed consent that
are not legally based (veracity covers those; see below). As such, it relates to is¬
sues such as what to expect from treatment (for example, how often do client
and counselor meet, for how long each time, what is the average cost), risks and
benefits (for example, improved relationships, feeling better, possible changes
in relationships), and procedural issues of the clinic (for example, video- or
audiotaping, payment schedule, record-handling). Trust in the therapeutic re¬
lationship is based on this principle of fidelity. Only when the therapist is trust¬
worthy is the client able to trust the therapist sufficiently to reveal painful life
stories and work on personally painful and sensitive issues.
Veracity refers to the legal aspects of mental-health care and to the honor¬
ing of all contracts made with clients. It addresses issues of confidentiality, lim¬
its to confidentiality, release of information, legal aspects of record keeping, le¬
gal aspects of payment arrangements, third-party-reimbursement issues, and
similar legally based concerns. In inpatient settings, veracity also is the prin¬
ciple that underlies least-restrictive-treatment alternatives as well as regulating
medication rules when clients refuse this route of treatment. Veracity thus as¬
sures that the legal rights of clients are respected and granted. Most clinics and
hospitals have brochures that spell out the legal rights of clients. Veracity is
granted to clients as long as the items in such brochures and in the informed
consent are respected by the institution. Clearly, fidelity and veracity are re¬
lated; violation of either will have a negative impact upon the clinician-client
relationship in that the client will feel violated and will perceive the clinician as
less than trustworthy.

Individual Self-Awareness
How a clinician views and applies the six ethical or moral principles is obviously
going to be guided by personal values, beliefs, attitudes, and interpretations and
hence requires good individual self-awareness. As indicated above, values guide
personal preferences and decision making; they reflect an individual’s feelings
or attitudes about something and translate into preferred actions or behaviors.
Rokeach, one of the early and foremost researchers into values, defined them
as “an enduring belief that a specific mode of conduct or end-state of existence
is personally or socially preferable to an opposite or converse mode of conduct
or end-state of existence” (1973, p. 5). However, a value is often actually com¬
prised of more than a simple preference or one single belief but rather is made
44 CHAPTER TWO

up of a complex set of beliefs that affect choices from at least one of three per¬
spectives: evaluative, emotional, and existential. Evaluation refers to a judgment
of right versus wrong or good versus bad. It is related to morality in that sense.
It is important to note, however, that although values and morality influence
each other, they are not the same. Some values can be intensely moral (that is,
driven by the evaluative perspective), whereas others reflect choices that have
nodiing to do with morality. For example, an individual chooses a vegan lifestyle
for moral (evaluative) reasons if the choice is based upon a belief that vegan¬
ism protects the environment and the rights of animals; it is not based on a
moral decision if the choice is made strictly due to the belief that this lifestyle
is more conducive to the health of the individual. Obviously, in many cases val¬
ues such as this one reflect a combination of reasons, leading the discussion to
a definition of the emotional and existential dimensions of values.
The emotional dimension refers to decisions based on whether the choice
helps the individual feel positive rather than negative emotions. For example,
a clinician may choose a location for a practice based on where she or he feels
better. A sunny southern-exposure office may be chosen over a different locale
because the clinician enjoys the sunlight pouring into the therapy office. This
decision may be made even though the office is on the third floor and has no
elevator. Such a location is in violation of the Americans with Disabilities Act
and may well reflect a choice that is unethical according to some professional
ethical codes. In other words, the value, if it were based on die evaluative di¬
mension, would be bad, not good. Finally, the existential dimension of values
or preferences refers to the likelihood of the choice creating meaning for the
decision maker. Often clinicians have made the choice to pursue a career in the
mental-health professions because they hope that this professional path will
lead to a meaningful life. The decision has less to do with whether it is the right
or wrong choice from a moral perspective, and may not even involve a con¬
scious emotional dimension, though it is likely that the clinician will also feel
good as a result of the work.
It is clear at this juncture that values are intensely personal and are driven
by highly idiosyncratic perceptions of reality and backgrounds. Values develop
in a social, cultural, socioeconomic, and even geographical context. They are
profoundly influenced by parents, families, communities, cultural groups, reli¬
gious affiliations, societal forces, friends, mentors; the list goes on. They reflect
the individuals worldview that grew out of these experiences and influences, as
well as the persons philosophy about life and understanding of the world. The
more similar two individuals’ life experiences are, the more similar their values
will be. This includes client and clinician: If client and clinician have highly dis¬
similar backgrounds, chances are that they will also hold dissimilar values. Re¬
search has shown that client-clinician value similarity leads to better and faster
treatment outcomes (Cottone and Tarvydas, 1998). This finding suggests that
dissimilar values can hinder or slow treatment. However, in all likelihood this
 SELF-AWARENESS SKILLS 45

•is true only for dissimilar values of which the clinician is not aware. An excellent
means ol keeping values dissimilarity from adversely affecting treatment is the
process of values clarification, or the exploration and achievement of individ¬
ual self-awareness.
Individual self-awareness about values is important because clinicians can¬
not hide their values from their clients. Values are reflected in too many ways,
including nonverbal behavior, office setup, location, and dress. Even choice of
theoretical orientation reflects values. For example, choice of Adlerian inter¬
vention reflects a value of social interest and social striving; reality therapy is
based on a value system of individual responsibility and quality of the individ¬
ual lifestyle; rational emotive therapy values the rational; existential treatment
is based on values of self-determination and freedom with responsibility (Cot-
tone and Tarvydas, 1998). It is for this reason that some writers endorse includ¬
ing a clinicians dieoretical orientation and its meaning in the informed consent
(for example, Cottone and Tarvydas, 1998). Clients are exposed to clinician val¬
ues at all times, in subtle and not so subtle ways. Values will enter treatment
through numerous subtle and obvious routes, including through the clinicians
language, differing responses to various client statements, pushing of agendas
(also called indoctrination), failure to inform clients of alternatives to suggested
solutions or interventions, imposition of personal views, and others. Values also
affect all aspects of treatment, including data collection, diagnosis, treatment
planning, relationship and rapport, goal setting, perceptions of solutions, choices
of topics in session, selection of intervention strategies, differential reinforce¬
ment of clients, messages of agreement and disagreement with the client, termi¬
nation decisions, and more. Only through self-awareness and self-exploration
will individual clinicians be able to identify how their values enter all of these
interactions and processes.
Identifying personal values that may or may not be relevant to treatment is
a difficult process. Research has indicated that, in general, mental-health-care
providers share belief in the following rights and responsibilities of clients
(Cottone and Tarvydas, 1998):

• the right to personal freedom

• responsibility toward others
. responsibility for personal decision making within the confines of
capacity
• the right to respect for their individuality
. the right not to be dominated, manipulated, or indoctrinated
. the right to make and learn from their own mistakes

An exploration of personal values can begin there, but must not end
there. An infinite array of values may enter the client-therapist relationship.
Additionally, there is an infinite array of choices that at first glance would not
appear to have an impact on the professional relationship. Even some of these,
46 CHAPTER TWO

however, may at times and in subtle ways influence therapeutic rapport. For ex¬
ample, on the surface, it would appear that a choice of owning a cat should not
in any way become an issue in the treatment of a client. What if a client presents
who hates cats, makes fun of people who own cats, has killed cats, and so on?
How will the clinician react? This may seem like a silly example, but this is in¬
deed how values can enter treatment in unexpected ways. Other values, choices,
and preferences are much more likely to cause concerns; many of these are
rooted in issues of religion or spirituality, sexuality, parenting, and similarly
highly emotionally and morally charged topics. It is precisely these values that
beg questions of whether clinicians should habitually refer certain clients,
should work only with clients who share certain life experience, should work
only with clients with similar backgrounds, and so forth. Each clinician will
have to make personal choices about this. Following are some topics that tend
to raise the issue of value similarity or difference between client and clinician.
Knowing where the clinician stands with regard to these and similar topics will
help in the decision making process about what to do with a client who holds
opposing values.

Common Therapy and Counseling Topics That Involve Values:

abortion • issues of power in intimate
alternative health care choices relationships
animal rights • marriage and cohabitation
assisted suicide • organized religion
birth control choices • parenting
career choices • personal responsibility
child abuse • politics
child neglect • premarital sex
childlessness by choice • racism, sexism, other -isms
conduct vis-a-vis authority • religious practices
figures . religious preferences
criminal activity . sexual orientation
death and dying • sexual practices
dietary choices • substance use—legal drugs
disrespect of others • substance use—illegal drugs
domestic violence • suicide
elder abuse • traditional sex role orientation
educational aspirations . unsafe sex practices
gang membership • weight and weight loss
health care choices • working parents
infertility
 SELF-AWARENESS SKILLS 47

Many other personal values need to be clarified in the clinicians mind be¬
fore working with clients. The values clarification process begins with an ex¬
ploration of areas where values enter, which is in virtually all aspects of hu¬
man life. Once areas and options have been explored, choices are made about
which values to endorse. Of course, this is not a static process. People have the
right to change their minds and opinions about matters. However, it is im¬
portant at least to think about where a clinician seems to stand at this mo¬
ment in time. If no firm stand is taken after careful deliberation, that is a stand
as well. It merely implies that the clinician is undecided and will have to see
how she or he will react when a given value comes up in treatment. Once
choices about values have been made, the crucial third step in the process is
to act in accordance. It is certainly admirable to have chosen a value, for ex¬
ample, of protecting and respecting all life. However, if the clinician then goes
out and kills an animal and mounts the head to display on a wall, a certain
level of incongruence has entered this persons life. In other words, once val¬
ues have been explored and chosen, authentic living will require the clinician
to live by these values. Not living by a value may make it so subtly present in
a clinicians life that it is not recognized as a value and enters treatment in¬
advertently and in an unexplored manner. Having clarified and lived by cer¬
tain values will help the clinician become quickly aware of those instances
when clinician and client values conflict and may cause problems in the thera¬
peutic relationship. There may be some values that will lead the clinician to
make referrals if clients strongly endorse the opposite. For example, a mental-
health-care provider who firmly believes in the sanctity of life and hence op¬
poses all suicides would have great difficulty helping a client who enters ther¬
apy to prepare for an assisted suicide. Table 2-1 provides a few individual
self-awareness areas that can be explored by trainees in an attempt to clarify
their values. The items included are based on the thirty-six values identified
by Rokeach (1973) as essential or central life values. Of these values, half rep¬
resent terminal values, that is, values that are relevant to choices central to a
persons end-state of existence; half represent instrumental values, that is, val¬
ues relevant to choices about mode of conduct. For each instrumental value
the clinician can clarify where on a continuum personal preference might
fall. For example, the continuum for ambitious to unambitious could be bro¬
ken into numerical subcategories ranging from 1 = very ambitious to 7 — very
unambitious and levels of ambitiousness in between. It can be further broken
down into topical subcategories such as ambitiousness in the context of work,
family life, hobbies, housing, car selection, with level of ambition differing de¬
pending on the area of life to which it is applied. The listing in Table 2-1 is not
to suggest that these are the only values clinicians need to clarify; it is merely
included as an impetus or starting point for self-exploration.
48 CHAPTER TWO

Rokeach’s Central Life Values

Instrumental Values Terminal Values

Ambitious to Unambitious Comfortable Life

Broad-Minded to Narrow-Minded Sense of Accomplishment

Capable to Incapable World at Peace

Clean to Unclean World of Beauty

Courageous to Cowardly Exciting Life
Forgiving to Unforgiving Equality
Helpful to Unhelpful Family Security
Honest to Dishonest Freedom
Imaginative to Unimaginative Health
Independent to Dependent Inner Harmony
Intellectual to Nonintellectual Maturity
Logical to Illogical National Security
Loving to Unloving Pleasure
Loyal to Disloyal Salvation
Obedient to Disobedient Self-Respect
Polite to Impolite Social Recognition
Responsible to Irresponsible True Friendship
Self-Controlled to Impulsive Wisdom

Interpersonal Self-Awareness
Once clarity about individual values has been gained to at least some degree,
attention can be turned toward values that are implied and choices that are
made in interpersonal contexts. Interpersonal self-awareness relates to all six of
the moral or ethical principles outlined above (that is, autonomy, beneficence,
and so on) in that all of these principles are clearly applied in an interpersonal
context when related to counseling or therapy. The granting of autonomy may
be affected by a mental-health-care providers interpersonal stance of creating
dependency. If creating dependency is a value of the clinician, it is likely that
this value may be imposed on clients to the detriment of granting autonomy
and self-determination. Similarly, thinking that the clinician always has all the
answers in relationships and knows better than the client what needs to be
done may result in violations of beneficence. Decisions may be made that are
good for the client from the clinicians perspective but bad for the client given
the client s preferences and familial or cultural context. An interpersonal stance
 SELF-AWARENESS SKILLS 49

Skill Development Recommendations

Recommendation 2-1 Using the list of therapy topics that invite value
judgments, determine your stance on each. Then think about how you would
feel about a client holding an opposite value. Given your reaction to such a
client, what woidd be your best course of action (for example, referral, collab¬
oration, supervision)?

Recommendation 2-2 Using Table 2-1, rate each instrumental value on a

scale of 1 to 7 (as defined in above) and sort the terminal values in order of
their importance to you. Look at your results. What do they suggest about
how your values may hinder or support your career choices in the mental-
health field?

of distrust and lack of loyalty on the part of a clinician can affect fidelity and ve¬
racity in that this clinician may be less than truthful or reliable. Given that in¬
terpersonal beliefs, attitudes, and values can enter the ethical and professional
relationship with clients, clinicians need to explore how they behave and what
they prefer in relationships. A variety of interpersonal dynamics needs to be ex¬
plored in this context to gain interpersonal self-awareness.
Some of the more important and obviously applicable interpersonal dy¬
namics are fisted in Table 2-2. These may not be the only interpersonal values
that enter into the therapy relationship and into ethical decision making. How¬
ever, they give the reader a starting point, as well as an idea about what kinds
of interactions and patterns to explore. Many additional interpersonal values
may emerge for a given counselor or therapist. These are best explored as they
arise, either in therapeutic or other relationships. Their impact on how the cli¬
nician relates to a client needs to be evaluated as objectively as possible. Some¬
times such objective evaluation may require the seeking out of a consultant or
supervisor who can help the counselor realize blind spots. The reality is that
every human being has developed a certain interpersonal style over a life¬
time. This style is not static and continuously evolves as new experiences accu¬
mulate. How clinicians relate in their personal life will greatly influence or be
mirrored by how they relate to their clients. A clinician who has problems with
intimacy in life in general may have difficulty developing an empathic relation¬
ship with a client that feels sufficiently supportive and caring for the client
to feel secure and willing to self-disclose. A counselor who is uncomfortable
around people may communicate this interpersonal awkwardness to clients
who in turn may feel as though they are causing the clinician discomfort and
may search for the reasons within themselves. A therapist with poor social skills
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52 CHAPTER TWO

may be unsuccessful in establishing therapeutic rapport not because of in¬

sufficient caring or empathy, but because of interpersonal mannerisms that are
offensive or uncomfortable for the client.
The first step in developing interpersonal self-awareness is to recognize
what interpersonal patterns are possible; Table 2-2 will help the clinician get
started with this step. The second step has to do with identifying how, in each
category of relating, the counselor or therapist actually behaves in relationships.
Table 2-2 provides possible patterns for each interpersonal issue, providing the
pattern first as it may manifest if there is an over-expression, then an under¬
expression, and finally a healthy expression of a given trait. Third, the mental-
health-care provider then has to evaluate how this pattern of behavior may af¬
fect clients and influence the therapeutic relationship. Fourth, choices may
need to be made to alter certain interpersonal patterns before beginning to en¬
gage in counseling or therapy. If such alterations are necessary, it will behoove
the clinician to seek out personal counseling or therapy for some assistance.

Cultural Competence and Sensitivity

All mental-health-care providers must develop cultural self-awareness. Devel¬

opment of cultural self-awareness requires clinicians to evaluate their level of
cultural sensitivity and competence, that is, their perceptions of and attitudes
about other cultural groups. In fact, gaining the skills and knowledge necessary
to deal with a racially, ethnically, and culturally diverse clientele, through intro¬
spection and learning, is deemed as important to a clinicians education as gain¬
ing the basic skills and knowledge of counseling or therapy (Iijima Hall, 1997).
Perhaps the best place to start is by looking at how a cultural group is defined.
Traditionally, when members of society think of cultural groups, they think of
labels such as race and ethnicity. Culture, however, is actually a broader term
that is inclusive of more groupings than those based on race and ethnicity.
In thinking about cultural diversity, the term race is often used. Race, how¬
ever, refers strictly to a biological classification that is based on physical and ge¬
netic characteristics, with only three primary races identified, namely, Cauca¬
soid, Mongoloid, and Negroid. Ethnicity, a slightly more inclusive label, refers
to a shared social and cultural heritage as may be identified, for example, for
Asian Americans or Alaska Natives. Clearly many more than three groups exist
that would fit this definition. Culture, the broadest term, refers to any group
that shares and transmits within it a certain set of values, beliefs, and/or learned
behaviors. Such transmission can occur across generations through the teach¬
ing, both advertent and inadvertent, of shared values and rules, or can be con¬
ducted purposefully and planfully with new members, as occurs in gay and les¬
bian cultures. For example, members of the Jewish faith constitute an ethnic
 SELF-AWARENESS SKILLS 53

‘group with a shared social, cultural, and religious heritage; however, they do
not constitute a race. Within the Jewish faith, a number of cultural subgroups
may exist depending on the level of orthodoxy of their religious beliefs and
practices. Similarly, W hite members of society constitute an ethnic group that
has a number of cultures (or cultural subgroups) within it, such as Irish Ameri¬
cans, Italian Americans, German Americans, and so forth, each of which shares
a learned set of values, attitudes, beliefs, or behaviors.
In other words, race breaks down further to ethnicity, which in turn may
cross racial boundaries (for example, a Native American individual who has a
biological race combining Mongoloid and Negroid). Similarly, ethnicity breaks
down further into cultures, which in turn may cross ethnic boundaries (for ex¬
ample, a gay individual who has an African American and Alaska Native ethnic
identification). Individuals can belong to several cultural groups at once (for ex¬
ample, one maybe upper-middle class, Caribbean African American, and physi¬
cally challenged), they may have varied ethnic backgrounds and identify with
more than one ethnic group (for example, a person may be Italian American
and Navajo, identifying primarily with a Navajo upbringing but also incorpo¬
rating Italian American values), and they may be biologically racially mixed (for
example, an individual may have one Caucasoid and one Negroid parent). In
fact, in modern society, most clients will have such multiple identifications and
diverse backgrounds. Clearly, race, ethnicity, and culture are not identifiable by
looking at the outside of a person or even at easily observed behaviors, an as¬
sumption often made in day-to-day life. To understand a client’s racial, ethnic,
and cultural identity, careful questioning is needed to assess that person’s identi¬
fication and perception. The group with which the client identifies most (in
which the client claims heritage) becomes that individual’s reference group and
will have the strongest impact with regard to having shaped behaviors, atti¬
tudes, and values (Phinney, 1996).
Although ethnic or cultural status often overlaps with minority status of a
group of people, this is not always so. Minority status as relevant in the counsel¬
ing or therapy context has nothing to do with the actual number of people within
a specific group. Instead, a minority group has been most fittingly defined as

A group of people who, because of physical or cultural characteristics, are singled out
from others in the society in which they live for differential and unequal treatment, and
who therefore regard themselves as objects of collective discrimination. . . . Minority
status carries with it the exclusion from full participation in the life of the society
(Wirth, 1945, p. 347).

This definition characterizes a number of groups in American society who

experience oppression and, as a result, are not able to participate fully in soci¬
ety as a whole. It also separates the conceptual identification of what consti¬
tutes a minority from the numerical concept. For example, in many countries,
women suffer oppression at the hands of males, rendering them a conceptual
54 CHAPTER TWO

minority, despite the fact that they are a numerical majority. Using this defini¬
tion, other minorities may include individuals with physical disabilities, the el¬
derly, gays and lesbians, and individuals who are economically disadvantaged,
depending on whether, as a cultural group, they perceive themselves as receiv¬
ing differential or unequal treatment. Thus, clinicians in a culturally diverse so¬
ciety work not only with individuals who are diverse in terms of their ethnic or
cultural backgrounds, but possibly also in terms of other avenues of oppression.
In recognition of the diversity of the population inside and outside of the
United States and the need to provide adequate and appropriate mental-health
services to all ethnic, cultural, and minority members of a given society, the
American Psychological Association, the American Counseling Association,
and the National Association for Social Workers, along with other professional
organizations, have expressed strong support of the need for mental-health¬
care providers to be culturally sensitive, and for training programs to help meet
this need. For example, the American Psychological Associations ethical guide¬
lines clearly state that “psychologists are aware of cultural, individual, and role
differences, including those due to age, gender, race, ethnicity, national ori¬
gin, religion, sexual orientation, disability, language, and socioeconomic status”
(American Psychological Association, 1992, p. 1599). Similarly, the need for in¬
clusion of cultural issues in the training of all therapists was advanced by the
National Conference on Graduate Education in Psychology (American Psycho¬
logical Association, 1987) when this committee stated that “psychologists must
be educated to realize that all training, practice, and research in psychology are
profoundly affected by the cultural, subcultural, and national contexts within
which they occur” (p. 1079). Obviously then, there is growing pressure from
professional organizations, as well as from individual practitioners, for thera¬
pists to become culturally sensitive to meet the needs of a culturally diverse
population and clientele (cf., Iijima Hall, 1997; Ponterotto, Casas, Suzuki, and
Alexander, 1995).
Cultural sensitivity and competence are developed through introspective
work and require a great deal of self-exploration and personal openness on the
part of the developing mental-health-care professional (Singelis, 1998). This
effort is not only worthwhile but also meets the spirit of contemporary profes¬
sional ethical codes for the mental-health professions. It is best applied toward
the development of cultural competence that has three major components: cul¬
tural awareness, cultural knowledge, and cultural skills. Simply put, cultural
awareness is gained through self-reflection and respect for others, as well as
through the strong recognition of and belief in the notion that difference does
not equal deviance (Namyniuk, 1996); cultural knowledge can be accumulated
via familiarization with cultural, anthropological, historical, and related events
involving or affecting all cultural and ethnic groups with whom a clinician an¬
ticipates working (cf., chaps. 5-9 in Ponterotto, Casas, Suzuki, and Alexander,
1995); and cultural skill is developed through learning about alternative ap-
 SELF-AWARENESS SKILLS 55

proaches to intervention, reduction in prejudicial or stereotyped use of lan¬

guage, and political activism (Ivey, 1995). Clinicians who strive to be culturally
sensitive and competent need to be able to claim all three of these traits as a
part of their repertoire of skills and beliefs. Entire books have been written to
help mental-health-care providers develop these sensitivities (for example,
Hogan-Garcia, 1999; McGrath and Axelson, 1993; Singelis, 1998). Each of the
three categories deserves further exploration, and an overview is provided in
Table 2-3 (adapted from Johnson, 1993).
It is worth noting that cultural sensitivity not only can be learned, it can
also be measured (Ponterotto and Alexander, 1996). This measurement is based
in the belief that regardless of how well trained a counselor is in certain multi¬
cultural skills or how well he or she chooses techniques or tests based on the
client’s cultural and ethnic background, ultimately any tool is only as good (that
is, as multiculturally competent) as the person using it. In other words, “what
is of paramount importance is the clinicians multicultural awareness, knowl¬
edge, and interpretive skill” (Ponterotto and Alexander, 1996, p. 651). A num¬
ber of instruments—for example the Cross-Cultural Counseling Inventory-R
(LaFramboise, Coleman, and Hernandez, 1991), the Multicultural Awareness-
Knowledge-and-Skills Survey (D’Andrea and Daniels, 1991; D’Andrea, Dan¬
iels, and Heck, 1991), and the Multicultural Counseling Inventory (Sodowsky,
Taffe, Gutkin, and Wise, 1994)—exist for this purpose. The interested reader
is referred to Suzuki, Meller, and Ponterotto (1996) and McGrath and Axelson
(1993) for more detail as well as exercises and self-report measures.

Cultural Awareness
Cultural awareness refers to the process of recognizing personal biases, prej¬
udicial beliefs, and stereotypic attitudes or reactions. Gaining awareness has
to precede modification of behavior and attitudes, and can be a painful effort
as clinicians begin to recognize that they are not free of recalcitrant prejudi¬
cial behaviors and beliefs. Later, the Skill Development Recommendations will
concretize this process, which will also be described briefly in the following
paragraphs. A good first step toward gaining awareness involves taking a look at
the cultures and minority groups of which clinicians are a member to review
personal cultural backgrounds, cultural assumptions, and cultural stereotypes.
This may involve taking a look at country of origin, gender, sexual preference,
language, skin color, physical limitations, cultural practices, and any other per¬
sonal traits that may be cultural in nature or that may have resulted in the dif¬
ferential, perhaps unequal treatment by the clinician. In so doing, clinicians
need to recognize that while there have been some consistent recipients of op¬
pression, over the years the focus of prejudice has shifted from culture to cul¬
ture. Further, the degree of bias against a given culture may have waxed and
waned, but may have remained present at all times in one form or another. As
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58 CHAPTER TWO

trainees begin to identify the minority, ethnic, or cultural groups of which they
are members, they must contemplate the experiences and influences that were
the result of being a member in that group.
Once identification of personal backgrounds has taken place, new mental-
health-care providers can shift to assessing their day-to-day reactions to differ¬
ent situations and different people to determine their biases and prejudices. As
such, as trainees go through their day, they may begin to make an effort to be¬
come aware of personal reactions to people from different cultures and minor¬
ity groups. Most people do not routinely assess such reactions. However, it is
an important process on the road to becoming culturally aware. Internal reac¬
tions to ethnic jokes, for example, may provide valuable information to help the
clinician develop self-awareness. Behavior while interacting with someone who
is culturally different from oneself can be attended to and understood with new
awareness. Most new therapists may recognize for the first time that they truly
react differently with people from other ethnic, cultural, or minority groups, a
realization that sometimes causes concern or embarrassment. However, sham¬
ing the clinician is not the point of assessing daily reactions. Rather, the point
is to help trainees realize that everyone, even the most open-minded individ¬
ual, has been influenced by societal and familial training. It is highly unlikely
that anyone exists who is completely free of biases and differential reactions.
The point of assessment is to begin to become conscious of these reactions, not
to chastise oneself for them. It can be helpful to attend to any undue general¬
izations from one member of a group to all members of that group; to take stock
of the cultural heritage or ethnic backgrounds of people with whom the thera¬
pist in training spends personal time; to evaluate honestly whether friends and
acquaintances are primarily of the same culture, and, if so, how this pattern
came to pass.
The next step in developing increasing awareness involves the seeking out
of experiences with different cultural, ethnic, or minority groups and begin¬
ning to identify stereotypic beliefs and biases. In so doing, it is helpful to keep
in mind that both positive and negative stereotypes can be destructive because
they move the clinician away from interacting with a client as an individual.
Once stereotypes have been identified, they can be evaluated for accuracy, since
for many stereotypes, a kernel of truth exists that renders them quite com¬
pelling. Testing stereotypes can be particularly difficult because it is always
possible to think of at least one example to verify a preconceived notion. There¬
fore, it is important to look at the bigger picture of reality in evaluating stereo¬
types. For example, there is a prevalent stereotype that minority members in
the United States exploit the welfare system. While some minority members
may be identified for whom this may hold true, the reality is that the majority
of welfare recipients are White, as are the majority of individuals who commit
welfare fraud.
 SELF-AWARENESS SKILLS 59

As the counselor striving to become culturally aware begins to monitor

personal reactions to different situations and people, awareness of personal
language will add an important component of self-exploration. Words selected
in general discourse (and hence in the therapy room) often are representative
of the thought processes underlying them. In addition to tracking the use of
blatant ethnic epithets, attention is also directed toward more subtle indicators
of bias and prejudice (Sharmaand Lucero-Miller, 1998). For instance, the clini¬
cian needs to explore the use of language that implies gender bias through choice
of nouns (such as chairman, policeman, congressman) or pronouns (such as use
of the generic “he”), as well as language that may reflect ethnic bias through in¬
appropriate phrases like “jew me down,” being “gypped,” “Indian giver,” “scotch
on a deal,” or “Irish temper.” The clinician must also explore biased assump¬
tions, for example, explanations or identifications of inappropriate behaviors,
such as lateness, seductiveness, anger, untrustworthiness, or thriftiness, based
on a persons ethnicity. Another prejudicial use of language is to refer to mem¬
bers of a culture different from ones own as “they” or “them.” This deperson¬
alizes and segregates members of that culture only to further perpetuate the
separation of groups. Once novice clinicians become aware of linguistic choices
that reveal prejudice or bias (whether intentional or inadvertent), they are
ready to attempt to select alternatives and to eliminate language that conveys
prejudice and bias, no matter how subtle.
Another important insight involves the awareness of the great differences
among persons within the same cultural or ethnic group. In fact, differences
within a group are often greater than those between cultures. One major within-
group difference clinicians must be aware of involves the cultural identity of an
individual, that is, the relative importance an individual places on his or her own
culture versus other cultures. Cultural-identity development has been concep¬
tualized in a myriad of ways. Although stage models have been criticized, one
commonly used way of looking at cultural-identity development involves in¬
dividuals going through a process of identifying with a number of successive
stages. There are several models to describe such developmental stages, in¬
cluding the Minority Identity Model (Atkinson, Morten, and Sue, 1997), Black
Identity Development Model (Jackson, 1975), and Negro-to-Black Conversion
Experience (Cross, 1971). As an example, Cross’s model views the develop¬
ment of an African Americans cultural identity as passing through four stages:
preencounter, encounter, immersion, and internalization. In the preencounter
stage, the individual holds disdain and hatred for being Black; in encounter, the
person begins to value herself or himself for being Black; in immersion, the in¬
dividual rejects and hates all that is not Black; and in the internalization stage,
the person gains a sense of self-confidence and security in who she or he is
and is able to embrace all cultures. A model not tied to any particular group
was presented by Phinney (1990), whose stages are labeled diffuse (unexplored
60 CHAPTER TWO

ethnic identity), foreclosure (commitment to a group based not on indepen¬

dent opinion but on parental or similar values), moratorium (exploration with¬
out commitment), and achieved (completed exploration which has resulted in
commitment to a group). Although stage models were developed originally to
describe the process encountered by minority group members, parallels have
emerged for White ethnic identity development (Carter, 1990; Helms, 1990;
Helms and Carter, 1990). Stage models may not best capture cultural iden¬
tity, however, as identity can shift across time and various experience factors
(Hayano, 1981), and as individuals may be at different stages with regard to dif¬
ferent identifications (Jones, 1990). The process of identifying a cultural iden¬
tity is valid not only for clients but also for the mental-health-care provider. In
recognition of this, to become culturally sensitive, clinicians must explore their
own cultural identity. To do so, they will need to examine deeply the sentiments
they hold about their own and other cultures to recognize commitments (or
lack thereof) to other ethnic groups.
Related to the issue of cultural-identity development, clinicians need to be
aware that individuals within a given culture will vary considerably with regard
to their level of acculturation. Acculturation is defined as the degree to which
individuals adopt the dominant society’s social and cultural norms to the ex¬
clusion of that of their own (Dillard, 1983). Acculturation is typically not a mat¬
ter of endorsing one set of cultural norms versus another, but rather refers to
the degree of incorporation of values or attitudes derived from both cultures.
There are many factors that may affect level of acculturation, including socio¬
economic status, number of generations that have been in the United States,
educational and employment opportunities, and geographical location. Gaug¬
ing clients’ levels of acculturation is an important part of getting to know them
and involves an evaluation of several factors, including the degree to which tra¬
ditional cultural practices are followed and the native language is used in think¬
ing and speaking (cf., Gibbs and Huang, 1989). Four levels of acculturation have
been identified (for example, Dana, 1993): traditional (adherence to the “birth”
culture), assimilated or nontraditional (adherence to majority culture), bicul-
tural (adherence to birth and majority culture), and marginal (lack of adher¬
ence to either culture). Level of acculturation will affect how clients interact
with members of both cultures and may influence the therapeutic relationship.
For example, if a Native American client appears very committed to Native cul¬
ture, therapy might make use of metaphor and storytelling, a commonly used
technique in Native culture, to resolve problems. Once again, clinicians also
need to work toward awareness of their own level of acculturation to further
clarify personal cultural identity. To assist with the process of clarifying per¬
sonal cultural identity, several scales have been developed. They are very spe¬
cific to the cultural background of the client, and they exist for most cultural
groups represented with great frequency in the United States. For example,
the Developmental Inventory of Black Consciousness (DIB-C; Milliones, 1980)
 SELF-AWARENESS SKILLS 61

and the Racial Identity Attitude Scale (RIAS; Parham and Helms, 1985; Pon-
terotto and Wise, 1987) can be used. For Hispanic clients, a variety of scales
exist that must be carefully chosen according to the subgroup of American His-
panics to which the client belongs (for example, the Acculturation Scale for
Mexican Americans [Cuellar, Harris, and Jasso, 1980]). Unfortunately, some
ethnic subgroups exist in the United States for whom satisfactory acculturation
scales have not yet been developed, despite a few attempts in the literature.
One example of such a subgroup is Alaska Natives of Eskimo descent (for ex¬
ample, \upik and Inupiat; Dana, 1993). For clients of cultural backgrounds for
whom no good acculturation measures exist, a clinical interview that will at
least attempt to get at the relevant issues (such as language, lifestyle choices,
exposure to majority culture, adherence to traditional ways) is of critical im¬
portance (Kohatsu and Richardson, 1996). Clinicians can follow a similar pro¬
cess in their own self-exploration.

Cultural Knowledge
While awareness is being established, the clinician also strives to become more
knowledgeable about cultural issues. The definition of cultural knowledge is
broad and multidisciplinary, requiring individuals to utilize many resources.
Courses, workshops, and seminars are obvious avenues for gaining accurate
knowledge about the many issues related to culture. A number of additional
possibilities are presented below. Cultural knowledge is critical for many rea¬
sons, including the fact that accurate information may help dispute any stereo¬
types that mental-health-care providers have become aware of about a group,
and will lead to better appreciation and understanding of different cultures. In
general, if used appropriately, knowledge will assist counselors to be better
able to interact effectively with members of other cultures. However, caution
must be exercised so that newly acquired knowledge is not represented as the
truth about all members of any given group. Such stereotypic or overgeneral¬
ized use of knowledge can be destructive and can get in the way of being truly
effective and empathic (Namyniuk, 1996).
Knowledge gathered from books is best not limited to a single discipline,
and optimally starts with gaining a firm and accurate understanding of the his¬
tory of the United States in general, and the history of different ethnic and cul¬
tural groups in particular (for example, Tataki, 1993; Zinn, 1995). Acquisition
of such knowledge may include an investigation of the history of immigration;
the introduction, role, and history of slavery; and the conquest of the conti¬
nent. It is important to remember that history books can be biased and selec¬
tive in their reporting and that it is often difficult to find books that provide a
balanced perspective on history. In addition to gaining a historical perspec¬
tive on the role of racism in the United States, it is important to recognize the
role of racism, sexism, and heterosexism in contemporary society. Integrating
62 CHAPTER TWO

historical information with current statistics and data on poverty may provide
added insights into the lives of many minority and cultural groups. Further,
much has been written about economic and political pressures that come to
bear on minorities within the United States. Such reading will help clinicians
recognize the adverse effects bias can have on the minority members who be¬
lieve and adopt (or adapt to) the prejudices toward their groups, as well as other
groups within society (Johnson, 1993).
The path toward cultural knowledge includes the reading of books within
the mental-health professions, on topics such as the psychology of racism. These
readings must also include a review of empirical information about cross-
cultural differences within the United States. However, a word of caution about
this literature is in order. Some of this research, particularly projects com¬
pleted prior to the 1980s, focused on comparing different cultural groups with
European Americans, implicitly establishing White Americans as the cultural
norm against which other cultures were compared to identify differences and
similarities. Consequently, the results are frequently (mis)interpreted within
a context of Whites as the ideal norm. Clearly, this is an inherent bias against
cultural groups other than Whites that must be considered and compensated
for when reading such research reports. The reader interested in more infor¬
mation about cultural biases in research is referred to an excellent overview
of cross-cultural-therapy research by Ponterotto and Casas (1991) as well as
Matsumoto (1994).
In the process of becoming culturally knowledgeable, mental-health-care
providers will learn that the dominant theories of counseling and therapy in the
United States were developed by White Europeans (predominantly male) and
may not have universal applications. Traditional personality theories as cur¬
rently taught in most mental-health programs emphasize values and world¬
views that are ethnocentric in nature; specifically, they tend to be Eurocentric,
reflecting the European cultural heritage of majority culture. Personality the¬
ories were developed to provide a context in which to explore individuals with
regard to their behaviors, values, beliefs, attitudes, language, relationship, and
so forth. All of these aspects of what it means to be human are entirely culture-
bound (Armour-Thomas and Gopaul-McNicol, 1998; Barnouw, 1985). To look
at these variables in clients or oneself without knowing the cultural context in
which they developed is likely to distort what is expressed. For instance, most
primary personality theories focus on the individual and state as a basic prem¬
ise that it is important for children to individuate and separate from their fam¬
ily. From this perspective of individualism, the indicators for a clients progress
toward health would be lessened reliance on family and others along with in¬
creased independence. Continued dependence or reliance on family or larger
social networks would be viewed as a sign of pathology. Such a viewpoint would
clearly not be compatible with cultures (for example, Asian American) that em¬
phasize a perspective of collectivism, that is, the importance of the family or
 SELF-AWARENESS SKILLS 63

community and the role of the individual within it (Singelis, Triandis, Bhawuk,
and Gelfand, 1995).
Further, it is important for mental-healdi-care providers to realize that
mental-health services are not universally held in high regard. Some cultures
place greater emphasis on seeking assistance from family members or com¬
munity elders, while other cultures see any sign of mental illness as a disgrace
to the family that must be hidden from all (Suzuki, Meller, and Ponterotto,
1996) . Some minority members view mental-health services as either being ir¬
relevant to the everyday struggle for survival they face or as being yet another
tool for the White majority to pacify and control minorities. Finally, clini¬
cians also need to become knowledgeable of the institutional barriers that may
prevent members of some cultural and ethnic groups from seeking and using
mental-health services (LaFramboise and Foster, 1989; Sue, Allen, and Con¬
away, 1978). There are many possible reasons for the underutilization of mental-
health services by minority group members: the perception of some clients
that mental-health-care providers are insensitive to diverse needs; fear that
clinicians may try to impose personal values upon clients; and inability to ac¬
commodate to the hours and days of operation and the amount of charges
for services.
The counselor must also become knowledgeable of the fact that there is no
single universally accepted definition of “normal” and that the standard of what
constitutes acceptable behavior will vary from one culture to another (Lum,
1999). Thus, clinicians need to learn not to rigidly apply one single definition of
mental health across all clients and need to recognize that culturally valued traits
will play a role in the behavioral manifestation of a client s personality. Cultures
vary greatly in what they consider to be a problem or an appropriate strategy
for coping within a given situation (cf., Castillo, 1997; Dana, 1993; Iijima Hall,
1997) . What may constitute abnormality in one culture may be acceptable, if
not mainstream behavior, in another. Different cultures may also express the
same type of problem in different ways, choosing different idioms to describe
an essentially identical emotional level and type of pain (Matsumoto, 1994a).
As such, depression among mainstream White clients may conform to the cri¬
teria outlined in the DSM-IV, whereas depression among the Chinese may
manifest itself through a different set of highly somatized symptoms, such as
constipation, loss of appetite, and fatigue, with little expressed dysphoric affect
(Castillo, 1997; Dana, 1993). Some disorders appear to be culture-bound, ap¬
pearing only (or predominantly) in some, but not all cultures (American Psy¬
chiatric Association, 1994; Suzuki, Meller, and Ponterotto, 1996). This latter
phenomenon may be explained by the observation that different cultures rein¬
force different traits and behaviors. As any trait or behavior taken to an extreme
may result in pathology, different cultural groups will have different manifes¬
tations of pathology based on the types of traits they emphasize in their healthy
population (Alarcon and Foulks, 1995; Iijima Hall, 1997).
64 CHAPTER TWO

It is particularly critical to gain extensive knowledge about the primary

group or groups with which clinicians anticipate doing the bulk of their work.
For example, if a therapist were to conduct therapy in rural Alaska, it would be
in the therapist’s (and clients’) best interest to learn about Alaska Native cul¬
tures, particularly about the Native groups who live in neighboring areas. If a
counselor were to work in a city with a predominantly Hispanic population, such
as El Paso, Texas, it would be in everybody’s best interest for the counselor to
learn about Hispanic culture and, if at all possible, to speak Spanish. Not only
does this knowledge enable the clinician to be more effective with clients from
these cultures, but it will also lead to greater credibility. Clinicians must never
overlook the most important source of knowledge about their clients culture:
the clients themselves. Clients can be an especially valuable source of infor¬
mation as they will provide the mental-health-care provider with their personal
perspective of their culture, information that may prove invaluable in assess¬
ment, case conceptualization, and the development of a treatment strategy
(Brems, 1998a).
If at all possible, clinicians are encouraged to learn the native language of
the clients with whom they will be conducting treatment. Although a difficult
task, it will pay considerable rewards in the increased rapport and respect that
will be gained from clients. Certainly, learning a language is a difficult process
and therapists may never be completely comfortable conducting therapy in
their second language. However, as a bare minimum counselors need to learn
a few common words of greeting and farewell, as well as commonly used terms
or phrases. If nothing else, trying to learn a second language will give mental-
health-care providers a better appreciation and empathy for those clients who
are themselves learning a second language, namely, English!
Beyond reading and taking classes or workshops, one of the most impor¬
tant avenues to gaining knowledge about different cultures is to become in¬
volved in firsthand experience (Lum, 1999). There are many different avenues
to gain this experience and trainees are advised to take advantage of as many as
possible. One possible approach is to attend various cultural events that are of¬
fered by or about the culture. These might include dances, plays, movies, and
lectures. A word of caution here is for the clinician to remember that these are
merely pieces of the culture, not complete reflections of the entire cultural pro¬
cess and heritage. This caution is necessary because many people will attend
cultural events that highlight the artistic or romantic aspects of a culture to the
exclusion of other aspects. If these were the only contacts with a given culture,
the counselor would derive a highly distorted understanding. Relatedly, it is
helpful to seek out opportunities for interaction with members of other cul¬
tures, preferably including both professional and personal involvement. For in¬
stance, professionally speaking, there may be opportunities to volunteer time
at a community mental-health center that offers special programs for members
of a specific culture or that is located in a neighborhood that is predominantly
 SELF-AWARENESS SKILLS 65

comprised of minority members. On a personal level, opportunities need to be

sought out for interaction with members of other cultures on a social level. All
professional and personal efforts to learn more about a cultural or ethnic group
whose members the therapist anticipates treating will not only lead to more
knowledge and experience, but will also have the added benefit of increasing
visibility, and hence added respect, among the people in that group.
It is presumed that all contemporary graduate programs in the mental-
health professions teach cultural competence and sensitivity. Courses and cur¬
riculum on these topics can be further enhanced through practica and intern¬
ships that involve a culturally diverse clientele. If this cannot be achieved solely
through careful selection of practicum or internship sites while in graduate
school, graduate training can be augmented by additional volunteer experi¬
ences, as well as by supervised employment attained upon graduation. Coun¬
selors need to take responsibility to encourage their supervisors to challenge
them with a culturally diverse clientele, given the limitations and parameters of
a specific clinical site. If the choice is available to trainees, they can select a
practicum or internship site located within a culturally diverse neighborhood
or city. Throughout all of these experiences, culturally sensitive supervision is
a critical component. Within supervision, focus should be placed, as appropri¬
ate, on the counselors experience of different types of clients. Through this use
of supervision to monitor reactions to culturally different clients, the therapist
will learn to avoid repeating any previously learned biases and stereotypes.

Cultural Skills
Clinicians’ awareness and knowledge of cultural issues will have to be trans¬
lated into skills to be of use to clients. The process of becoming culturally com¬
petent therefore must include the acquisition of new skills and the possible
adaptation of existing skills. Perhaps most importantly, mental-health-care
providers need to learn and apply appropriate communication skills that are
adapted to meet the needs of each individual client (Kim, 1994). Cultures dif¬
fer in their emphasis in communication. Some individuals are most concerned
about the clarity of their message, some about the relationship between speaker
and listener, some about the evaluation they will receive based on their ex¬
pression, some about the impositions made by their remarks, and some about
the effectiveness of their communication (Kim, 1994). Clinicians need to learn
to recognize their clients’ and their own personal preferences in communi¬
cation and adjust accordingly. For example, a client who tends to express is¬
sues in treatment in a manner that is mostly concerned with how the clinician
will respond to the client (that is, is most concerned with being evaluated) may
have a tendency to withhold facts that are perceived as potentially leading to
negative evaluation. Another client, who is mainly concerned with not hurt¬
ing the clinician’s feelings may not self-disclose information that is perceived as
66 CHAPTER TWO

potentially critical of the clinician. Concern for relationship in communication

tends to be correlated with cultures that are more collectivistic; concern for
communication of facts and effectiveness with cultures that are more individ¬
ualistic (Triandis, 1989).
Some cultures may place greater emphasis on nonverbal communication,
members of these cultures are less likely to view talking therapies as ideal thera¬
peutic modalities. The clinician will have to develop skills that can accommodate
these needs (Cargile and Sunwolf, 1998). For example, among some groups,
silence may be a sign of respect, not resistance. Skillful use of silence will be a
respectful means of expressing cultural competence with such clients. Using a
client’s native language can be invaluable. Regardless of language, skillful clini¬
cians keep their communication free of bias and prejudice, eliminating inap¬
propriate phrases, terms, and expressions from their vocabularies.
Culturally competent clinicians have to acquire the skills to identify and
carry out the techniques that will be most effective with any given client. Rather
than approaching each and every client in the same manner, counselors recog¬
nize the need to modify their therapeutic approach depending on the needs of
each individual client (Ponterotto, Casas, Suzuki, and Alexander, 1995). With
increased sensitivity to the differences in how clients from different cultures
may express their individuality and connectedness, therapists will not patholo-
gize a client based on such differences (Brislin, 1993; Singelis and Brown, 1995).
Skillful mental-health-care providers are also aware that there are marked dif¬
ferences within any given culture and are careful not to make broad general¬
izations of the types of treatments that will work for all members of that culture
(Suzuki, Meller, and Ponterotto, 1996). Thus, therapists need to have the skills
to be flexible in their therapeutic approach and use this flexibility in a compe¬
tent and appropriate manner when dealing with clients from different cultures.
Also crucial is the ability to place the appropriate amount of attention on
the role of culture in therapy. That is, clinicians must neither overemphasize nor
underemphasize the importance of culture in therapy with a given client. To do
so, counselors need to have the skills to evaluate a situation effectively and to
assess the level of attention that needs to be given to culture with each client.
Therapists recognize that stereotyping and generalizing are acts destructive to
the therapeutic process, and that even within a given culture, members will
have varying degrees of commitment to traditional cultural values and behav¬
iors. This skill is dependent upon having attained a level of ethnorelativism that
helps the counselor to neither overemphasize nor ignore the impact of culture.
Ethnorelativism can be considered the opposite end of a continuum rang¬
ing from ethnocentrism to ethnorelativism. Most people develop an ethnorela-
tivistic perspective by passing through a number of fairly predictable stages,
formulated originally by Bennet (1986). The starting point for most humans is
an ethnocentric one; individuals learn through what they are exposed to, which
early in the life span is generally their own culture. Once confronted with the
 SELF-AWARENESS SKILLS 67

diversity of others in the greater environment, Bennet suggests that people’s

first response is denial that the difference exists. This is followed by a defense
of their own position and characteristics over those of the group perceived as
different, since difference is perceived as a threat. Generally, this attempt at
defending their position is followed by a minimization or trivialization of the
differences once they can no longer deny that differences exist and once indi¬
viduals realize that their own perspective is neither the only one nor necessar¬
ily the correct one. At this level, people still believe in a universal law, but rec¬
ognize that it may manifest or express itself differently among different groups
of people. From minimization people generally move to an acceptance that oth¬
ers can be different without being worse. They begin to realize that there is no
universal truth, but rather that values, attitudes, and beliefs can be completely
different and can stem from a different worldview. Such acceptance is followed
by an adaptation of personal behavior and attitudes, a move that tends to in¬
crease flexibility in multicultural contexts and in general. Once individuals have
learned to integrate their own experiences, values, attitudes, and beliefs with
those of people from cultural backgrounds different than their own, they finally
think ethnorelativistically. Such individuals begin to recognize that behavior,
values, and attitudes have to be understood within a larger context and that
people cannot be judged or stereotyped according to worldview perspectives
(or based on comparisons with generalized group means). Although some au¬
thors (for example, Dana, 1987) suggest that mental-health-care providers in
general need to have attained at least Stage Four (acceptance), it appears likely
that only clinicians who have at least reached Stage Five will be able to engage
in sensitive and competent counseling and therapy (Brems, 1998a). It is pos¬
sible to accept another person without interacting with her or him; such ac¬
ceptance is likely to incorporate an air of condescension or arrogance, attitudes
that do not appear conducive to rapport.
Ethnorelativistic clinicians will have the skill not to categorize individuals
according to their ethnic or cultural background, that is, not to treat all mem¬
bers of any given group as identical (Richardson and Molinaro, 1996). Although
the U.S. population is often categorized into five major groups, namely, Whites,
African Americans, Hispanic Americans, Asian Americans, and Native Ameri¬
cans, each of these broad categories has within it a number of subcategories.
For example, the broad category of Asian Americans contains a number of
smaller groupings, each with its own unique cultural background and heritage.
The group includes individuals whose cultural background lies in very diverse
countries including China, Japan, Samoa, North and South Korea, Vietnam,
and Guam. Further complicating this issue is the fact that even within each
of these country-based subgroups, there are further subgroups. For example,
within Vietnam, there is a significant proportion of ethnic Chinese who have,
over the years, maintained great autonomy from other Vietnamese. Further,
even within the Chinese-Vietnamese group there may be major differences
68 CHAPTER TWO

such as rural versus urban, rich versus poor, gay versus straight, Buddhist ver¬
sus Christian, and so forth. This example demonstrates how broad categoriza¬
tion of individuals ignores the numerous differences that exist within this larger
grouping. The same obviously holds true for other ethnic groups, with variables
such as country of origin, sexual orientation, physical abilities, socioeconomic
status, religion, and age.
Recognizing that institutional barriers may prevent members of some cul¬
tural or minority groups from utilizing mental-health services, clinicians need
to learn to become flexible in their provision of services (Namyniuk, Brems, and
Clarson, 1997). They recognize that the client cannot control some problems
and that nontraditional steps may need to be taken to help resolve the situation
(Brems, 1999). For example, if a client presents for therapy due to feelings of
inadequacy or depression, the intake interview may reveal that the individual
is the only culturally different student in a predominantly White university stu¬
dent body and that White students have been making racist comments. The
client, unable to make friends in the new setting and subject to ongoing dero¬
gation, soon begins to incorporate many of these negative perceptions into her
or his self-concept. In this situation, there is an outside force (racism at school)
that has had a direct and adverse impact on the client. Hence, focusing solely
on the client in an attempt to improve self-concept will most likely not be the
most effective intervention. Instead, therapy will be most effective if a three¬
pronged intervention is adopted that involves the client, the community, and
the university. By including interventions in the university setting, the thera¬
pist may be able to make an impact on the client s environment which in turn
may have a positive effect on self-esteem.
Consequently, culturally competent clinicians will want to cultivate an¬
other important set of skills: being agents lor social change (Hogan-Garcia,
1999; Monges, 1998). Clinicians need to learn how to eliminate any form of
discrimination, including that based on ethnicity, sexual preference, age, men¬
tal or physical limitations, religion, gender, and so forth. Being culturally sen¬
sitive, mental-health-care providers act to ensure that everyone has access to
the services and resources that are needed. In so doing, they take a proactive
advocacy stance to help victims of discrimination. Trainees need to recognize
that as clinicians they will be granted a great deal of power by their clients and
other community members. They must recognize their responsibility to use
this power to help eliminate discrimination in society, both directly and indi¬
rectly. Indirectly, the therapists will come to serve as an example of a nonbiased
individual. They will learn to be careful of chosen words and actions to convey
perceptions of equality of all persons and respect for individuals from all walks
of life. Counselors come to recognize that many clients will model their be¬
havior after that of the clinician. With this recognition, they learn to be careful
of any interpersonal interactions that might convey prejudice or bias, even of
the subtlest kind.
 SELF-AWARENESS SKILLS 69

Skill Development Recommendations

Recommendation 2-3 Choose several or all of the recommendations made

in the Cultural Sensitivity section and incorporate them into your daily life.
For example, take an inventory of your personal cultural background; explore
your circle offriends for its diversity or lack thereof; become aware of your
language and any reflections of racism or sexism; open yourself up to your
thoughts and feelings as you encounter individuals from other cultures; at¬
tend cultural events and evaluate your reactions; volunteer to work with indi¬
viduals from other cultu res; listen to the language and conversations of others
with an ear for racism or sexism. In opening yourself up to these experiences,
keep a journal of your thoughts and reactions. Review this journal regularly
with an open mind to slowly gain awareness of any prejudices, stereotypes,
and values that emerge.

Recommendation 2-4 Choose a cultural group (other than your own pri¬
mary group) with whose members you anticipate working in therapy or
counseling. Identify a mental-health professional from within that group and
ask for an interview. Interview that individual with regard to what you need
to know about working with members from that cultural group. Listen openly
and do not offend by making stereotypic assumptions.

When necessary and appropriate, mental-health-care providers will learn

ways in which to take direct actions to prevent or eliminate all forms of discrim¬
ination. This direct action can range from not condoning racist or sexist jokes
told in their presence to using the political system to create positive changes in
society. In becoming culturally skillful, therapists recognize that although the
primary purpose of therapy or counseling is to help enhance the quality of
clients’ lives, it is equally important to complement this individual approach
to improving life with a more general approach to enhancing the quality of
society. Thus, counselors will come to do everything possible to help create a
society that is more respectful and humane in its treatment of all persons
(Johnson, 1993).
Self-Care Skills*

We can shed those layers and layers of habits and

learned responses that lead to careless action
and thoughts. We can learn to look before we leap
and think before we act; we can stop living like moths
who are inevitably attracted to bright, dangerous
flames. We can shake free of our knee-jerk behaviors
and responses to life; we can let go of dissatisfying and
unhealthy patterns. And, as we become more mindful,
our innate wakefulness—our spiritual and inner
wisdom—begins to blaze forth.
Lama Surya Das, 1999, p. 191

For successful work with clients, counselors and therapists must first of all be
able to take care of themselves. Successful mental-health-care providers are
mentally healthy individuals who have good personal awareness and the will¬
ingness for introspection. Individual and interpersonal self-awareness in the
realms of values and cultural sensitivity were dealt with in detail in Chapter
Two. This chapter focuses on skills that facilitate broader individual self-
awareness, along with good self-care that keeps the clinician safe from the burn¬
out and impairment that can negatively influence therapy and counseling. Per¬
sonal mental health has to be grounded in good personal habits that honor the
needs of mind, body, and spirit. A wide range of self-care skills can help keep
clinicians grounded and healthy, physically and emotionally. It is not necessary
to select a particular lifestyle or personal health routine that is suggested here.
Each individual reader will need to decide whether any of the skills discussed
here can be incorporated into her or his personal life. Self-care is by definition
highly personal; opinions on what is right and wrong differ greatly and defen-

*This chapter represents a minor modification of an excerpt from Chapter 9 in Brems, C. (2000).
Dealing with challenges in psychotherapy and counseling. Pacific Grove, Calif.: Brooks/Cole.

70
 SELF-CARE SKILLS 71

siveness can occur quickly. It is recommended that readers peruse the self-care
chapter with an attitude of suspended disbelief and open-mindedness. None of
the suggestions are meant as directives; they are possibilities. It is hoped that
every reader will find something useful for her or his life and situation.
The most important goal of this chapter is to help mental-health-care
providers recognize the importance and value of tending to their own personal
physical and mental health and that such self-care best involves a routine that
is followed not rigidly, but with commitment and pleasure. A healthy clinician
will model good emotional and physical health for clients and will be more con¬
gruent than a practitioner who struggles personally with balancing physical,
mental, and spiritual needs and health. Self-care will be addressed from sev¬
eral perspectives: self-exploration and awareness, relaxation and centeredness,
personal habits, relationships, and recreation.

Self-Exploration and Awareness

“The sense of who one is, and of one’s empowering life vision, seems to be at
the core of long and creative living” (Jevne and Williams, 1998, p. 5). Self-
awareness and emotional stability of the care provider are important aspects
of good treatment as well as of burnout prevention. Therapists are con¬
fronted with difficulties by clients on a daily basis; in addition, they have to be
able to cope with their own life challenges. Being able to maintain self-esteem,
self-efficacy, and a basic sense of personal competence is critical during peri¬
ods of challenge (Wheeler, 1997). One important aspect of self-care—self¬
exploration—is of great assistance in the struggle to become more aware and
less prone to overreaction to clients. Self-exploration brings benefits not only
to practitioners, but also their clients. It combines with the work clinicians al¬
ready do around values clarification and cultural sensitivity development, and
as such provides additional concrete strategies for the creation of awareness
and insight. In general, emotional stability is achieved through the develop¬
ment of self-awareness. Self-awareness can lead to better professionalism; it is
also recommended to help therapists “flourish as human beings, who then
bring more than the minimum to their therapeutic work” (Johns, 1997, p. 61).
Figuring out what really matters in life is an important endeavor that some take
more seriously than others (Schwartz, 1995). Clinicians can hardly choose to
ignore this very important issue if they want to be aware, unbiased, and effec¬
tive mental-health-care providers who neither impose biases on their clients
nor succumb to impairment. There are many possible avenues toward self-
awareness and personal self-development from which clinicians can choose.
The following paragraphs focus on a few important strategies, but the list is by
no means all-inclusive.
72 CHAPTER THREE

Personal Therapy or Counseling

One obvious strategy that creates self-awareness is, of course, personal therapy
or counseling. One may wonder if this strategy even needs mention in a book
for mental-health-care providers. Actually, it appears that it does. Although
over 80 percent of mental-health-care providers report having been in personal
therapy in the past, only 22.2 percent of doctoral-level providers and 38.8 per¬
cent of master’s-level providers report being currently in therapy. The remain¬
der, a surprisingly large percentage (61.2 to 79.8 percent), rejected the idea
of current personal therapy for several reasons, including concern about the
value of personal therapy (15 to 17 percent), embarrassment about being a
client (13 to 15 percent), concern about confidentiality (12 to 16 percent), and
prior negative experiences with therapy (7 to 8 percent) (Mahoney, 1997). Ar¬
guments have been made that all therapists in training should be required to
be in personal therapy as well. This is a difficult issue that has not been empir¬
ically investigated. One can hardly disagree, however, that a counselor or ther¬
apist will be more effective and persuasive if personally convinced of the value
of personal therapy. To hold such a belief may then translate into practice even
without an imposed requirement from a training program or licensing agency.
Since readiness for treatment is a critical issue in outcome of therapy, imposed
personal therapy may be less effective than personal therapy that is initiated at
the discretion of the practitioner. As Johns (1997) points out, therapy’s or coun¬
seling’s “optimal value is likely to emerge at a time of readiness, through re¬
flective self-awareness which identifies a need, triggered by discomfort, uncer¬
tainty, the presence or absence of expected or unexpected feelings, unresolved
personal issues, challenge of expected beliefs or crisis or developmental tran¬
sitions in both professional and personal maturity” (p. 64). Each clinician will
have to decide which road to choose. If clinicians make the choice not to seek
therapy or counseling, they need to question the level of faith they place in the
process and whether they communicate that lack of faith to their clients. The
potential negative consequences of this are obvious.

Inner Work
Another excellent set of strategies for creating self-awareness is doing inner
work through various self-exploratory means such as reading, journaling, and
dream work. Reading does not require much explanation. There is a virtu¬
ally endless supply of books and manuals that help people explore their lives,
relationships, selves, dynamics, pasts, futures, feelings, thoughts, behaviors,
and on and on. The main caution in this regard is to be a careful consumer
and not to believe every self-help book that has ever been published. The In¬
ternet may be a good source for interactive reading resources that facilitate
self-exploration.
 SELF-CARE SKILLS 73

, Journaling was made popular as a legitimate strategy for self-exploration by

Pennebaker (1990). He conducted a series of fascinating experiments in which
he asked participants to write about things that were stressful for them to help
them get their emotions out in the open. He found that writing about stressful
life events and the emotions surrounding them was not only stress-reducing in
and of itself, but also helped participants improve coping ability as well as over¬
all health. Based on his research findings, Pennebaker has suggested that writ¬
ing is most helpful if it deals with both the experience and the emotions and
deep feeling involved in the experience. Such self-exploration leads to cathar¬
sis and insight, and has numerous extremely positive consequences for the
writer. It helps improve mood, increases coping ability, enhances the immune
system, and in general appears to promote better physical and mental health.
In other words, journaling appears to be a powerful strategy for clinicians wish¬
ing to prevent burnout or impairment. It is also an activity that easily fits into
a busy schedule as it can be engaged in anywhere and for brief periods of
time. There are virtually no drawbacks to this technique, although some have
warned that clinicians need to “guard against becoming morbidly introspective
or unduly passive by also emphasizing action” (Bayne, 1997, p. 190). This cau¬
tion, however, applies to most, if not all, self-exploratory strategies.
A third strategy for inner work is dream work, which is a familiar, power¬
ful strategy for most mental-health-care providers. Exploring ones dreams to
achieve insight can be accomplished relatively easily. The best strategy for re¬
membering dreams is to direct oneself to remember the dream upon awaken¬
ing. It is helpful to have a tablet of paper and pen or a tape recorder by the bed¬
side and to record the dream immediately upon waking from it, even if this is
in the middle of the night. Analysis of the dream then occurs the next day. It is
best to read a few books or take a class to decide which approach for analyzing
dreams is best for the individual. Not all approaches rely exclusively on Freud s
or Jungs work, although they are certainly the thinkers who have inspired the
work on dreams (cf., Freud, 1900; Jung, 1974). Many larger cities have dream
work groups that come together for the sole purpose of working on members'
dreams. There are several resources that may provide useful starting points for
clinicians interested in using this strategy, including books and tapes that can
be found in most popular bookstores (for example, Garfield, 1977; Johnson,
1986; Mahrer, 1989; Taylor, 1983; Ullman and Zimmerman, 1979).

Meditation
A final and perhaps most excellent strategy for developing self-awareness is
meditation, though this is not the primary purpose of meditation. Meditation
is a strategy that could appear equally appropriately in the section about re¬
laxation and centeredness, or in the section about relationships. It is such a
comprehensive and powerful strategy that it touches all aspects of a persons
74 CHAPTER THREE

life. The choice to place its discussion in this section was therefore somewhat
arbitrary. Meditation is not one thing; it is many things. It has many goals and
no goals; it is a difficult process and yet it is easy. Meditation is about finding
peace and stillness, about quieting the mind and being in the moment. In Le-
Shan’s (1974) book on meditation (perhaps the book cited most often as being
helpful in learning the process), he describes the goal of meditation as “access
to more of our human potential or being closer to ourselves and to reality, or to
more of our capacity for love and zest and enthusiasm, or our knowledge that
we are a part of the universe and can never be alienated or separated from it,
or our ability to see and function in reality more effectively” (p. 1). This is a
most complicated sentence for a book that sets out to simplify something, but
it is entirely accurate. Meditation returns the practitioner to a state of quiet
and calm and connects humans with their roots in the universe. Although it is
potentially the most calming practice of any of the self-exploration skills, it can
at times leave the practitioner feeling disturbed or confused. The benefits of
meditation have been researched and carefully documented in many places
(for example, Hirai, 1989; Wilber, 1993, 1997). Lama Surya Das (1999) pro¬
vides an excellent summary of the inadvertent positive consequences of con¬
sistent meditation practice and includes the following:

• it leads to greater calm, peacefulness, and awareness of inner resources

• it helps the mind empty itself of confusion and clutter
• it helps slow down minds that are restless or filled with angry, obsessive,
or fearful thoughts
• it brings about a sense of centeredness and balance
• it makes the senses and perception more vivid and powerful
• it assists with gaining greater insight into personal issues
• it reduces egoism and self-centeredness
• it increases the capacity for love, wisdom, and compassion
• it provides health benefits such as facilitating the healing process from
various severe illnesses
• it creates greater understanding of personal behavior
• it reconnects body, mind, and soul
• it opens the heart to others

Although some teachers say that meditation is best learned with a qualified
instructor, basic meditation technique is easily learned. Knowing basic tech¬
nique does not mean knowing how to meditate, and even teachers who have
meditated for years accede that it is the practice of meditation that is important,
not the goal or the outcome. Practiced over the long term, meditation helps the
practitioner develop a calmness and serenity that permeates all of life. It is the
ultimate technique for finding defenselessness, relaxation, and peacefulness in
life, all states of being that are highly related to well-functioning and preven¬
tive of burnout and impairment.
 SELF-CARE SKILLS 75

• There are many forms of meditation. Regardless of which form one

chooses, there is significant agreement as to the basic procedure, which is to sit
in a quiet place, either cross-legged on the floor with a cushion for support, or
on a straight-back chair with feet on the ground. The sitting posture is prefer¬
able as alertness is key to successful meditation, and lying down may lead to
drowsiness or sleepiness. Most resources recommend closed eyes; some sug¬
gest eyes partially open; only a few suggest eyes wide open (for example, Rin-
poche, 1995). Posture is erect but not rigid, comfortable but not too relaxed.
Most resources recommend a regular meditation schedule, with many recom¬
mending at least twenty to thirty minutes (and up to one hour) once or twice
per day. Some writers recommend mornings, others evenings. Perhaps the best
schedule is one that accommodates the practitioners life most realistically. If
evening meditation means that the practitioner falls asleep, morning practice
may be preferable; if morning meditation tends to be interrupted by family
members, evening practice may be superior. Some writers recommend timing
meditation so that it follows, rather than precedes, exercise. Being in a calm
state of mind before engaging in meditation is helpful but not a prerequisite.
For some, such calmness is achieved by means of exercise (traditional or medi¬
tative, such as yoga or t’ai chi). It is best to learn meditation in a quiet environ¬
ment that is private and without interruptions. Although advanced practition¬
ers can meditate anywhere, those still learning the practice tend to do better in
silence. Setting aside a specific spot for meditation can be helpful as it becomes
a conditioned stimulus for relaxation, calm, and introspection. Some practi¬
tioners choose to place meaningful objects in this space (such as flowers, can¬
dles, statues), whereas others prefer simplicity. Natural settings or a view of na¬
ture are very conducive to a meditative state. Wearing comfortable clothing is
helpful, especially clothing that does not constrict the waist, ankles, and wrists.
Breathing should be regular and tends to become deeper and deeper as well as
more rhythmic as one meditates; diaphragmatic breathing (see relaxation sec¬
tion below) is most conducive to reaching a deeply relaxed meditative state.
The simplest form of meditation merely focuses the mind on the breath.
LeShan (1974) categorizes this form of meditation as a meditation of the outer
way, as attention is focused on a process or item external to the mind. Another
meditation of the outer way is to contemplate an object by looking at it in¬
tensely from as many angles as possible during the entire meditation time.
Meditations of the inner way focus attention on ones own stream of con¬
sciousness without altering it. An example of a meditation of the inner way is
the bubble meditation described by LeShan (1974). In this meditation, the
person envisions the self sitting at the bottom of a pond, observing bubbles
floating upward through the water. As thoughts enter the mind, they are placed
in such a bubble and are allowed to drift upward through, and ultimately out
of, consciousness. Other types of meditations can have other foci, such as the
creation of compassion, the expression of lovingkindness (metta meditation),
76 CHAPTER THREE

the creation of awareness about feelings, the achievement of centering, or the

sending of healing thoughts. Meditation that is focused on observing ones
thoughts often is highly conducive to creating insight and self-awareness and in
the Buddhist tradition is referred to as vipassana meditation. What all medita¬
tions have in common is their focus on the moment; all attention and concen¬
tration is continually returned to the present moment as the past and future are
allowed to fade.
It is important to note that it is virtually impossible for most practitioners
to quiet the mind completely; thoughts will come and go. The successful prac¬
titioner is not the one who banishes all thought, but rather the one who is aware
of each thought as it arises, acknowledges it without getting caught up in it, and
then returns to the focal point of the chosen meditation. In fact, regardless of
which type of meditation is chosen, the universal experience is that it is ex¬
tremely difficult to keep the mind focused, whether the focus is inward as in
the observation of ones own thoughts, or outward as in the observation of one’s
breath or the contemplation of an object. The key to success is to continuously
bring the mind back to the breath, to the object, or to the thought bubbles, and
most importantly, to calmness. No one can keep the mind quiet for very long;
it is the effortless intention to let go of thoughts that brings on the positive ef¬
fects of meditation. Learning to quiet the mind by coming into the moment is
the key to becoming self-aware, connected to a larger cosmos, and defenseless
and accepting in relationships. There is no better self-exploratory and calming
technique than meditation. It is likely to influence all areas of a practitioners
life almost automatically with regular practice. Mental-health-care providers
should be strongly encouraged to begin to meditate and perhaps to seek out a
meditation teacher. It will be helpful for the interested reader to read more
about meditation by accessing additional resources, recommended samples of
which include:

1. Das, L. S. (1999). Awakening to the sacred: Creating a spiritual life from

scratch. New York: Broadway Books.
2. Goldstein, J. (1976). The experience of insight. Boston: Shambhala.
3. Goldstein, J, and Kornfield, J. (1987). Seeking the heart of wisdom.
Boston: Shambhala.
4. Kabat-Zinn, J. (1994). Wherever you go, there you are. New York:
Hyperion.
5. Kabat-Zinn, J. (1990). Full catastrophe living. New York: Delta.
6. Kornfield, J. (1993). A path with heart. New York: Bantam.
7. LeShan, L. (1974). How to meditate. New York: Bantam.
8. Rinpoche, A. T. (1995). Taming the tiger. Rochester, Va.: Inner
Traditions.
9. Suzuki, S. (1998). Zen mind, beginner’s mind. New York: Weatherhill.
 SELF-CARE SKILLS 77

Skill Development Recommendations

Recommendation 3-1 Choose one of the above-mentioned strategies and

read more about it. Once you have a deeper understanding of it, begin prac¬
ticing it at least once weekly. For example, once per week sit in meditation, ex¬
plore your inner life, or visit a counselor or therapist. It will be most helpful
to journal about this experience. For the greatest likelihood of impact, prac¬
tice this recommendation at least three months.

Relaxation and Centeredness

Another important set of self-care skills is that of relaxation strategies. Of all

people, mental-health-care providers are probably best informed about this
particular approach to self-care as they often incorporate relaxation strategies
into client care. They may not, though, apply relaxation strategies in their own
life as often as one would hope. The four most common strategies to achieve
a state of relaxation are breathing exercises, mindfulness, relaxation strategies
proper, and guided imagery. Of these four strategies, most clinicians are well-
versed in the latter two, and less familiar with the first two. Thus, breathing and
mindfulness will be covered in some detail whereas relaxation strategies and
guided imagery will be briefly reviewed.

Breathing Exercises
Deep and conscious breathing is a very simple and straightforward means
of achieving relaxation. Improper breathing, on the other hand, is a quick and
straightforward way to stress, tension, and uptightness. Many people hold
their breath during periods of great stress, and most never breathe consciously
at any point in their lives. In fact, most people pay no attention to breath at
all; it is an autonomic response they tend to rely on to just happen. Breath,
though, is very much affected by tension and stress, and changes and may
even seize momentarily in these situations. This sets up a vicious cycle since
uptight or improper breathing in turn increases stress in the body even further.
Learning to breathe deeply and consciously can be one of the most important
components of achieving stress reduction and mental and physical health. No
other strategy works better or faster than deep, conscious breathing to induce
78 CHAPTER THREE

a state of deep relaxation. Breathing exercises are an excellent prelude to all

relaxation strategies, including progressive-muscle-tension relaxation exer¬
cises, guided imageries, and other visualizations, both in personal practice and
with clients.
To learn healthful deep breathing for relaxation, it is best to watch a baby.
Babies automatically breathe in the most efficient and relaxing manner. Their
trick is to use their diaphragm as a means of pulling air more fully into the
lungs. Most individuals breathe using only their chest muscles (that is, the in¬
tercostal muscles between the ribs), an inefficient and less relaxing mode of
breathing. A person who breathes in this way has no detectable motion of the
abdomen during inhalation; merely the chest expands. Diaphragmatic breath¬
ing, which is relied upon during meditation and associated with states of relax¬
ation, serenity, and peace, on the other hand, is detected by observing the rise
and fall of the abdomen with each inhalation and exhalation. In diaphragmatic
breathing, the diaphragm (the large muscle between the thoracic and abdom¬
inal cavity) flattens with inhalation, moving the abdomen forward and creating
space for the lungs to expand with air in the thoracic cavity.
The best way to practice diaphragmatic breathing is to lie flat on one’s back
witii a hand (or both hands) on the stomach. As in most, if not all, breathing ex¬
ercises, it is best to place the tongue on the alveolar ridge (the soft tissue be¬
tween the roof of the mouth and the upper front teeth) and to exhale once,
forcefully and deeply (as well as noisily) through the mouth. All subsequent
breathing is done through the nose exclusively (unless engaging in a special
breathing exercise that specifies otherwise). To breathe diaphragmatically, on
inhalation the focus is on flattening the diaphragm against the abdominal
cavity, allowing the belly to rise gently. As this movement occurs, the lungs will
naturally fill with air. On exhalation, the diaphragm relaxes, the stomach re¬
cedes, and the lungs empty. This type of breathing can be engaged in any
rhythm. The slower the breathing the greater the state of relaxation If one
gasps for air between breaths, however, the breathing has slowed too much. It
is important to find a comfortable speed and rhythm and then to just observe
the breath. Once diaphragmatic breathing has been successfully practiced ly¬
ing down, it can be used in any body position and can be applied as a quick and
easy relaxation strategy anytime, anywhere. It can be used in the middle of a
stressful lecture, while sitting with a client, or during a job interview, and no
one will know. Its power of relaxation, however, will take hold immediately, es¬
pecially after prolonged practice in a relaxed setting.
Because diaphragmatic breathing is strongly associated with a state of re¬
laxation, it is not the preferred way of breathing during physical activity or ex¬
ertion. During activity, breathing is best conducted using the entire breathing
apparatus. In this type of breathing, the breath starts with the flattening of the
diaphragm and expansion of the abdominal cavity. The breath then moves up
 SELF-CARE SKILLS 79

•to the chest with the continued inhalation expanding the lower thoracic cavity
and then the upper chest cavity, finally raising the shoulders. Exhalation works
in reverse, with the shoulders dropping first, the lungs contracting, and the di¬
aphragm relaxing to flatten the stomach. This very rejuvenating breath is a
good breath to use at the end of a relaxation practice to become alert again. It
can also be an excellent means of overcoming fatigue and becoming reener¬
gized anywhere, anytime. A variety of other breathing exercises exists (for ex¬
ample, Schiffmann, 1996; Weil, 1995), but these two basic forms will get any¬
one started on the road to relaxation and better vital capacity.

Mindfulness Practice
Breathing can easily be combined with the practice of mindfulness, and in fact
can be a powerful way to begin to learn being mindful. Mindfulness, in turn, is
a helpful precursor for relaxation in general, and relaxation exercises in partic¬
ular. Its application is possible so constantly throughout life that it can be prac¬
ticed anytime, anywhere, with anyone. It is a mindset that develops and ulti¬
mately becomes second nature, and is very useful in coping with stressors of
daily life and in keeping focused on what really matters. Mindfulness is the
practice of stillness, centeredness, and full awareness in the present moment.
It involves conscious living and alert presence of mind; it helps bring awareness
into focus and directs attention to present actions and thoughts (Das, 1999).
Shantideva is said to have defined it thus: “Again and again, examine every as¬
pect of your mental and physical activities. In brief, that is the very way of ob¬
serving mindfulness.”
The easiest way to begin to learn mindfulness is to sit still and center at¬
tention on breath. Centering attention on breath means observing each in¬
halation and exhalation and their effects on the body—physical sensations in
the nose, the larynx, the lungs, the chest, and the abdomen. Full concentration
is placed on observing the subtle changes in the body as breath moves in and
out. Each small change in the body is noted and attended to with great aware¬
ness, but at the same time with total calm and stillness. Being involved with
each breath is true mindfulness of the breath, a centering and calming experi¬
ence that creates a very peaceful feeling of being in the moment.
Mindfully slowing down and centering does not have to involve sitting still
and breathing, although this is the easiest way to experience mindfulness and
practice it until it takes hold. Mindfulness can be practiced through any familiar
skill or activity by simply placing all attention and concentration on the activ¬
ity. As in the mindful-breathing exercise, every subtle movement and change
in the body is noted and appreciated for its complexity. If possible, the activity
can be slowed down to more fully appreciate the many subtle muscular move¬
ments and their incredible coordination. It is helpful to the generalization of
80 CHAPTER THREE

mindfulness into everyday life to pick a regular activity to couple with the prac¬
tice of mindfulness. Mindfulness provides a model for the feeling of serenity
centeredness, and peacefulness that is so helpful to relaxation. Thich Nhat
Hanh has written masterfully about the practice of mindfulness in day-to-day
life and teaches workshops on the subject. One of his preferred foci for mind¬
fulness is walking (Hanh, 1975).
The opposite of mindfulness is absent-mindedness and lack of attention.
Anyone who has ever left their house and later wondered whether they turned
off the stove or locked the door has experienced the opposite of mindfulness.
Activities were engaged in without attention to them and hence they were not
even consciously registered in awareness. Mindfulness brings a peaceful feel¬
ing that clearly focuses the mind on what is important—the present. In mind¬
fulness, attention is concentrated on the moment and all thoughts of the past
and future disappear, and along with them the anxiety and stress they may cre¬
ate. Whatever activity one is engaged in at the moment of mindfulness be¬
comes the center and reason of existence and is done for itself, not for an end
goal. In other words, what becomes important is the process, not the out¬
come. If mindfulness is applied to breathing, the focus is to breathe, not to sur¬
vive or relax. If mindfulness is applied to eating, the purpose is to savor the
food, to enjoy every aspect of eating, from chewing to swallowing, not to satisfy
hunger or get dinner over with so that something else can be done. Whole
books have been written on the topic of mindfulness. It certainly deserves that
much attention (Fields, 1985; Hanh, 1975). The few guidelines provided here,
however, suffice to initiate the novice into its practice. One final point is of
note: Mindfulness is excellent for work with clients as well. Clinicians who are
mindful are fully present with their clients and give them the complete and un¬
divided attention they deserve. Being a mindful mental-health-care provider
facilitates being an attentive listener, empathic responder, and insightful prob¬
lem solver.

Relaxation Exercises
Anyone who has achieved relaxed breathing and mindfulness is fully prepared
to begin relaxation through other means. Since most health-care professionals
are well versed in relaxation strategies, not much effort will be spent on them
here. The following quick review of relaxation strategies is meant mainly to re¬
mind clinicians to avail themselves of the very strategies they recommend to
clients. As mental-health-care providers learn to use this skill with clients, they
can also pay attention to how they may practice it in their own lives. (This skill
will be discussed in some detail later, in the context of client work.)
The idea of using relaxation strategies per se is based on the principle that
a body cannot be relaxed and anxious at the same time. Relaxation strategies
 SELF-CARE SKILLS 81

■have traditionally been employed to reduce general anxiety, induce sleep, pro¬
duce relaxation to facilitate coping with a specific anticipated event, or reduce
phobic reactions in specific situations. The two primary strategies that have
been developed are muscle tension relaxation and pure relaxation. In muscle
tension relaxation, muscle groups are first tensed through specific suggested
motions and then relaxed; the difference between the two states is then noted
in a mindful manner for the purpose of inducing relaxation. Simple or pure re¬
laxation exercises will focus attention on the same muscle groups but without
the initial experience of tension. The chosen muscle group is focused on with
the desire or direction to relax it. In using relaxation, a few cautions apply, both
for personal use and use with clients. Most importantly, it is necessary to re¬
member that:

• if pain occurs, the person relaxing may need to take a break from tensing
a certain muscle group
• if a floating feeling occurs, this is usually no problem unless the person
relaxing is prone to dissociation (which may be a contraindication for use
of relaxation)
• a feeling of heaviness is not only normal, but generally desirable unless
the person relaxing has a physical problem that is exacerbated by this (for
example, fibromyalgia)
• if the person relaxing sees colors or shapes, this is normal, but can be
stopped easily if perceived as unpleasant or disruptive by opening the
eyes
• if the person relaxing falls asleep (and this was not the purpose of the re¬
laxation exercise), it is best to awaken them (this is of course difficult if
the person has no guide; in such cases it is best to practice relaxation
sitting up)

Relaxation is best started with deep breathing, combined with mindfulness

of the breath. This slows down, centers, and focuses in the present the person
relaxing. It generally works best to progress from the periphery of the body to
the center. In other words, ones attention should move from the feet, hands,
calves, forearms, thighs, upper arms, head, face, neck, shoulders, to the torso,
in that order. Relaxation is contraindicated with individuals who are known to
have temporal-lobe epilepsy (complex partial seizures) and other seizure dis¬
orders. It needs to be used cautiously with people who are prone to dissocia¬
tion and with individuals who suffer from post-traumatic stress disorder. De¬
briefing with the person relaxing (that is, the client or oneself) after a relaxation
exercise is a helpful process that can make subsequent sessions more efficient
and useful through appropriate modification or changes. Various resources, in¬
cluding books, tapes, and scripts, are available to persons who would like to in¬
corporate relaxation strategies into their everyday life.
82 CHAPTER THREE

Guided Imagery
Guided imagery is also known under various other labels, including mental re¬
hearsal, covert modeling, and visualization. It is based on the principles of pro¬
gressive relaxation and social-learning theory, and can serve many purposes
beyond relaxation. Specifically, in addition to being used to induce relaxation,
guided imagery has been used for pain management, skills acquisition and en¬
hancement, self-exploration, and healing. The same cautions that apply to the
use of relaxation strategies are also relevant to use of guided imagery. Most im¬
portantly, caution needs to be applied when using guided imagery with indi¬
viduals who have a tendency toward dissociation, excessive anxiety, history of
trauma, and certain medical conditions (such as seizures, fibromyalgia, and
arthritis). For relaxation purposes, the procedure of guided imagery usually
starts with deep breathing, mindfulness, and a few simple relaxation com¬
mands. Visualizations of pleasant scenery are then used to induce a deeper
state of relaxation. It is important to remember that imagery does not have
to be limited to the sense of sight, but also involves the senses of hearing,
smelling, touching, and tasting. Scenes (including smells, tastes, and so on)
work best if individualized for each individual. However, prepared scripts and
tapes are also available, as are numerous books on the subject (for example,
Adair, 1984; Borysenko, 1987; Fogelsanger, 1994).
Guided imageries will be adapted to suit the purpose for which they are
chosen. In the context of clinicians’ self-care, the most likely purposes are re¬
laxation and self-exploration. Strictly for the purpose of relaxation, guided im¬
agery will usually focus on the imagery of pleasant scenes that involves all the
senses of the practitioner. Such guided imageries can start out with a fairly ge¬
neric script that can then be modified according to the preferences of the user.
As such, once a script has been used once, it is helpful to evaluate what worked
and did not work and to make the necessary modifications during the next
practice. Once a successful script has been developed, it can be taped individ¬
ually for the specific user and used again and again. Clinicians using guided im¬
agery for purposes of relaxation can purchase prerecorded tapes or can tape
their own in their own voice or diat of a friend. Similar scripts exist for purposes
of self-exploration. In this area it appears preferable to develop scripts and
tapes uniquely for the individual user. However, for novice users of guided im¬
agery for any purpose, it is quite helpful to make use of die many published
scripts and to modify them, rather than to start from scratch. Many books and
tapes are available. One excellent source for both is the Academy for Guided
Imagery in Mill Valley, California (415-389-9325). The Academy is also an ex¬
cellent training site for mental-health-care providers who want to learn more
about imagery. Some helpful books include:

1. Adair, M. (1984). Working inside out: Tools for change. Oakland, Calif.:
Wingbow Press.
 SELF-CARE SKILLS 83

Skill Development Recommendations

Recommendation 3-2 Every morning upon waking, engage in a breathing

exercise to center yourself. You may choose to do this before getting out of bed
(though be careful not to fall asleep again), or you may do so after you have
gotten up. Practice this skill for at least three months. Journal about your ex¬
perience with this exercise and evaluate its usefulness to you on a daily,
weekly, and monthly basis.

2. Borysenko, J., and Borysenko, M. (1994). The power of the mind to heal.
Carson, Calif.: Hay House.
3. Levine, S. (1987). Healing into life and death. Garden City, N.Y.:
Doubleday.
4. Levine, S. (1989). A gradual awakening. Garden City, N.Y.: Doubleday.
(accompanying tape available from Warm Rock Tapes, RO. Box 100,
Chamisal, N.M. 87521)
5. Naparstek, B. (1994). Staying well with guided imagery. New York:
Warner.
6. Rossman, M. (1993). Mind/body medicine: How to use your mind for
better health. New York: Consumer Reports Books.

Healthy Personal Habits

There is virtually no limit to the number and variety of personal health care
habits a person can develop and engage in. The most obvious and essential ones
are included here for a brief discussion. There are no definitive answers or rec¬
ommendations, and advice that has been published elsewhere is often contra¬
dictory and confusing. This section attempts to distill this advice down to the
components that tend to be fairly universal to most research findings and sug¬
gestions in the literature. It addresses diet and nutrition, physical activity, rest,
physical self-awareness, and awareness of nature.

Nutrition
Nothing stimulates defensiveness more easily than talking to people about
their food choices and eating habits. Very few people, including clients, super¬
visees, friends, family members, and others, feel completely comfortable with
the choices they have made in this regard and hence the defensiveness when
84 CHAPTER THREE

the topic is raised. Despite the dangers inherent in raising the topic, diet and
nutrition need to be discussed because they are an absolutely essential part of
personal well-being and well-functioning. Food choices affect physical and emo¬
tional health, a connection not many people seem to make (for example, Null,
1995; Sorrier, 1995; Werbach, 1999). There are many types of diets people can
choose; a simple differentiation is the omnivorous-versus-vegetarian diet. Om¬
nivores eat animal (flesh and dairy) and plant foods; vegetarians avoid flesh
foods, but not necessarily all animal products. Specifically, the vegetarian
lifestyle has large variation within it, including but certainly not limited to:

• ovo-lacto-vegetarianism (vegetarians eating eggs and dairy products)

. veganism (vegetarians who shun all animal products; some even reject
honey)
• pesco-vegetarianism (vegetarians who eat fish; a contradiction in terms
since there is no fish that is not an animal)
• part-time-vegetarianism (people who claim to be vegetarians but con¬
sume flesh products on occasion)
• macrobiotics (a special vegetarian diet that is largely grain- and vege¬
table-based with many fermented products, and limited use of spices and
herbs)
• raw-food diets (vegetarians who only eat raw foods, including a large vari¬
ety of nuts, seeds, and sprouts)

Most commonly when people think of a vegetarian diet, they think of the
ovo-lacto-vegetarian lifestyle. A vegetarian diet in and of itself is not more or
less healthy than a diet that includes meat (that is, an omnivorous diet). Al¬
though research has identified longer lifespans and fewer medical problems
for certain population groups who live vegetarian lifestyles, such as Seventh-
Day Adventists, these populations have healthy vegetarian lifestyles. What
makes a vegetarian lifestyle healthy is the conscious choice of wholesome, life-
sustaining foods. Junk food vegetarians are no healthier than junk food omni¬
vores. The choice to live a healthy vegetarian lifestyle has many implications,
ranging from health concerns to political and social statements. Vegetarianism
is a choice that can be made for several reasons:

• health: This type of diet is healthier in terms of reducing the number of

medical problems and extending the lifespan
• spiritual: This type of diet is considerate of animal life and animal well¬
being
• environmental: This type of diet supports a more sustainable economy
that is easier on the planet in terms of pollution and resource use
• financial: This type of diet can be cheaper than a meat-based diet
• global: This type of diet requires less acreage than a meat-based diet
and could allow ample food supplies for all people on earth if practiced
universally
 SELF-CARE SKILLS 85

• An omnivorous diet can also meet these criteria under certain conditions.
Specifically, a subsistence lifestyle as used to be practiced by indigenous popu¬
lations can be respectful of the land, the earth, the animals who are hunted,
and the people who prepare the food. This lifestyle, however, is quickly fading,
even in remote areas of the planet. The mainstream American omnivorous diet
encourages appalling conditions for animals who are raised for the mere pur¬
pose of slaughter. Although important, this issue is beyond the purpose of this
section. Readers are referred to John Robbins’ Diet for a New America (1987),
or Michael W Fox’s Eating with Conscience: The Bioethics of Food (1997). As
alluded to above, even a vegetarian diet can be unhealthy and disrespectful. A
maximally healthy and respectful vegetarian diet requires that the practitioner
of the lifestyle make certain healthy and important choices in addition to the
choice to avoid flesh products. Most importantly, the healthiest diet is one that
is whole-foods based and organic. Non-whole-foods vegetarian diets can be junk
food diets that have no healthful impact. Typical American processed foods,
such as white flours, processed salts, sugars, and unhealthy fats such as hydro¬
genated oils and transfatty acids, are the greatest obstacles to health next to
toxic and polluted foods such as nonorganic vegetables grown with unhealthful
fertilizers, herbicides, and pesticides, and nonorganic, non-free-range meats
and dairy products.
Nutritional guidelines and choices recommended for use or avoidance are
summarized in Table 3-1. Although at first blush this type of diet may seem to
require an inordinate amount of time for food preparation, it really does not re¬
quire much more energy and time than any other type of diet once a routine
has been developed. The transition to this way of eating can be mastered in
steps, making the adjustment more acceptable and easier for the body.
In addition to making conscious choices about the foods that are con¬
sumed, it is helpful to put some thought into eating habits per se. The average
American eats more calories per day than are needed to sustain life. In fact,
some researchers are beginning to suggest that calorie restriction (which by
others has been reframed as a return to normal calorie levels) is the single most
important variable in predicting length of lifespan and the only variable that
may actually extend the human lifespan. Eating on the run is not a healthful
habit. Eating slowly and consciously can be extremely relaxing. Making time to
sit down for meals, as opposed to eating in the car, in front of the television set,
or while talking on the phone or running errands, is a centering activity that
also facilitates proper digestion and absorption of nutrients. Chewing food well
is an important and often-overlooked component of the digestive process and
its absence can account for a variety of health problems. Eating slowly and en¬
joying the food that is eaten rather than just wolfing it down results in greater
relaxation and better health (Millman, 1993). Taking time between bites and
swallowing each bite before taking the next one assures that food is eaten in
proper quantities and can be digested well (Reid, 1994). Making eating an
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 SELF-CARE SKILLS 89

occasion to be relished is a nice way of centering oneself through an activity

that needs to be engaged in anyway.

Physical Activity
Almost as touchy as the topic of food is the issue of exercise. Everyone knows
that being active seems to be related to better health. Nevertheless, only a
small portion of the American public actually follows this advice. The type and
level of activity that is optimal for the average person appears less clear-cut
than the generic advice to seek out an active lifestyle. There seems to be agree¬
ment around the need for daily exercise. The incorporation of daily exercise is
best accomplished by building a routine of exercise into daily life that can be
followed even, or especially, on tiresome and stressful days. For physical activ¬
ity to be healthful, overexercise needs to be avoided as much as underexercise.
In other words, it is important to avoid compulsive exercise that stresses the
body even further. It is best to choose activities that result in enjoyment and
that do not hurt physically. A good balance of aerobic exercise and stretching
appears to be useful, and the incorporation of the enjoyment of the outdoors
can add a relaxing and rejuvenating component. It is helpful to seek variety in
terms of exercising, as this keeps motivation up and repetitive-stress injuries
down. In designing a physical fitness plan it is best to keep in mind four aspects
of physical activity and health: strength (or muscular power); stamina (or aero¬
bic capacity and endurance); suppleness (or flexibility); and sensitivity (or bal¬
ance, rhythm, and timing). All four of these components need to be condi¬
tioned and attended to. Incorporating exercise that involves strength, stamina,
suppleness, and sensitivity into vacations is another excellent way to unwind
and keep the body healthy. Hiking, backpacking, kayaking, and similar activi¬
ties fit the category of exercise while also being extremely pleasurable and re¬
laxing in an outdoor setting that can be healing to mind, spirit, and body.
The three foremost aerobic forms of regular (if not daily) exercise that are
relatively safe to engage in and that build strength as well as stamina are walk¬
ing, swimming, and cross-country skiing. Walking is an excellent exercise that
is easy to fit into busy schedules, inexpensive, and possible anywhere and in
any weather. Swimming is another form of activity that has a low incidence of
injury and can be greatly enjoyable while giving maximum benefits. Cross¬
country skiing is another aerobic exercise that is easily learned and has great
physical benefits. Many other forms of aerobic exercise exist (dancing, tennis,
racquetball, running, step classes, and on and on), and it is important to sample
several before settling into a routine. Varying these forms of exercise is also a
good idea to keep up motivation and enjoyment. Running, one of the more
popular forms of aerobic exercise because of its time efficiency, has many
drawbacks, as does high-impact aerobics. It is best to consult with a physician
before engaging in potentially more injurious forms of aerobic exercise.
90 CHAPTER THREE

The best supplements to aerobic regimens to build suppleness and sensi¬

tivity are stretching exercises, mild workouts with free weights, and systematic
exercise routines such as t’ai chi, chi gong, and yoga. Most of these require
some initial learning curve and lessons until a basic routine has been mastered.
Once learned, however, they can be carried out anywhere, anytime, and are ex¬
tremely flexible. They can easily be engaged in at the office, even for ten min¬
utes between clients. Additionally, exercises such as t’ai chi, chi gong, and yoga
have a strong relaxation or even meditative component and can rest the mind
while working out the body. Specific yoga and chi gong routines can be devel¬
oped with an instructor for specific healing purposes and can be extremely use¬
ful for dealing with particular ailments or disease /recurrence prevention.
If a person is currently sedentary, it is important to check with a physician
before starting a rigorous exercise program. Once the decision is made to in¬
corporate exercise into daily life, it is a good idea to start exercising slowly,
gradually increasing length and intensity. The “main principle in physical ac¬
tivity is gradually and comfortably to be more active” (Bayne, 1997, p. 188).
Jumping in full force can lead to injury and quick disillusionment. Thirty min¬
utes of exercise per day most days of the week is a good goal to aim for. Some
research has suggested that exercise does not have to be done in a continuous
period. Instead, exercise can be incorporated into a busy schedule by doing a
little bit at a time, several times a day. Thayer, Newman, and McClain (1994)
showed that just ten minutes of brisk walking had a positive effect by increas¬
ing energy and reducing tension for up to two hours! It is important to let the
body dictate what is comfortable, rather than to use some external standard of
having to work out for a certain length of time or to go for a certain criterion
of distance, weight, or similar standards. Some people can easily engage in
strenuous aerobic exercise without negative effects, whereas others are better
served by less-stressful activity. One thing to remember while engaging in all
forms of exercise is that very strenuous activity increases the number of free
radicals in the body and thus increases the need for proper nutrition, especially
the intake of antioxidants. Prolonged strenuous exercise can actually damage
the body significantly and can leave the exerciser with a weakened immune sys¬
tem that is more vulnerable to colds and other minor ailments. Some sports
physicians, for example, indicate that running a marathon can leave the im¬
mune system compromised for up to six weeks (K. W Klingler, personal com¬
munication, 8 June 1998).

Rest
Often when lives get very full with activity and commitments, time is taken
away from sleep. This is a bad idea as the cost of reducing sleep can be high.
The lack of alertness during the day after a sleep-deprived night may undo the
time savings of that extra hour of staying awake the day before. Getting plenty
 SELF-CARE SKILLS 91

.of sleep each night is a most important self-care habit. The number of hours re¬
quired varies greatly from individual to individual. The best sleep routine is one
in which the person awakens in the morning without an alarm clock. This may
require going to bed earlier or starting the day later than most other people.
The development of routines best follows the dictates of the body rather than
some external criterion of what “should” or “should not” be done. Some rou¬
tines, unfortunately, are dictated. If children have to be at school at a certain
time or an employer expects an employee at work at a certain hour, then rou¬
tines have to be adjusted. However, the number of hours of sleep does not need
to be compromised even then. Some people like to incorporate a rest period in
the middle of the day. For some, this practice causes a sluggish and drowsy re¬
sponse, but for others it is excellent. Experimentation with what works is again
the best method of judging whether to incorporate this routine into one’s life.

Physical Self-Awareness
It is very important to learn to recognize warning signals and pleasure signals
that come from within ones body. Bodies often know before the conscious
mind does that stress is mounting and changes need to be made. Paying atten¬
tion to the body and letting it decide when to slow down is an important self-
awareness skill and health issue. Bodily symptoms and changes can give an in¬
dication of when someone may need medical attention, when there is a need
to change exercise and nutrition routines, or when the need for relaxation has
to be met. Regular physical checkups can be useful even when the body ap¬
pears to be symptom-free. It may be preferable to consult naturopathic physi¬
cians for this type of medical care, as they are more attuned to subtle symptoms
and bodily changes. Allopathic medicine is still preoccupied with disease and
illness as signaled by strong discomfort and overt symptoms. Non-mainstream
(and non-Western) medicine instead looks for patterns and changes in func¬
tioning that can be early warning signs about disease or less than optimal health
(for example, Pizzorno, 1998; Reid, 1994). The definition of health in allopathic
medicine is merely the absence of disease; in naturopathic medicine (and in
traditional Chinese medicine, for that matter), the definition of health is much
broader, involving the well-functioning of body, mind, and spirit. Being in
touch with one’s body is a good idea, and a few critical health-monitoring rou¬
tines can be incorporated by everyone, based on need and risk factors. For ex¬
ample, monthly breast self-exams, daily blood pressure checks, and similar
simple health care routines can be life-saving skills for those with risk factors
for particular diseases (cfi, Pizzorno, 1998, for an excellent book on taking
charge of monitoring one’s own health).
Taking an interest in ones health care during times of disease or symptoms
is another important aspect of physical self-awareness. Blind faith in physicians
is often misplaced as allopathic medicine often pretends to have the answers to
92 CHAPTER THREE

a problem when the suggestion really is at best an educated guess. Being in¬
formed about treatment alternatives and not simply accepting every recom¬
mendation ever made by a physician is responsible self-care. Medicine has very
few definitive answers, and many mild physical problems have a wide range of
possible solutions. The overuse of certain medications, such as antibiotics, has
resulted in health care crises of frightening proportions (for example, Garrett,
1994). The treatment of symptoms rather than causes is another problem of
allopathic medicine that can only be overcome by responsible self-care and ac¬
tive involvement in one’s personal health care. Taking a pill to alleviate a symp¬
tom may be easier than searching for the cause of the symptom, but in the long
term it tends to create more problems. Symptoms are often signals that the
body (or mind) is in distress. Covering the symptom merely prolongs the
exposure to the cause of the problem. For example* taking medications for
heartburn is a sure way of inviting disaster if the root cause of the problem is
not addressed (Pizzorno, 1998). Even more invasive medical procedures are
often confused with being healing when they are really only palliative. Bypass
surgery is an important example. The bypass may fix the clogged artery, but it
will not extend life unless substantial lifestyle changes are made that address
the root cause of the disease. Removing the symptoms (that is, the arterial clog)
does not deliver health. Making responsible choices about risk-benefit ratios
of prescribed treatments is another important self-care skill. Chemotherapy
for cancer is an example of the cure sometimes being worse than the disease
(Moss, 1996). The exploration of treatment alternatives is often left to the pa¬
tient. This generally means that the patient who is not self-aware will blindly
follow the allopathic physician’s lead, taking whatever is prescribed without ex¬
ploring whether preferable alternatives exist (for example, herbal remedies,
nutritional interventions, physical therapies).
The relevance of this issue to therapists and counselors rests in the fact
that health care is an active skill and perfect health is only obtained if active in¬
volvement is part and parcel of physical self-care. Perfect physical health, in
turn, is an important prerequisite to mental health. If clinicians cover their own
physical symptoms with palliative methods and fail to seek root causes of their
ailments, they most likely will model the same passive consumption of health
care for their clients. This is dangerous practice and goes against the idea of
empowering consumers to take an active and deciding role in their own health
care (physical and emotional). The lesson is to practice what is preached.

Involvement with Nature

The final personal-care habit is somewhat related to relaxation and stress re¬
duction. Being in touch with nature is a centering aspect of life. Too many
people in modern life spend hardly any time outdoors. The fact that the indoor
environment can be perfectly adjusted in terms of warmth, humidity, and simi-
 SELF-CARE SKILLS 93

Skill Development Recommendations

Recommendation 3-3 Choose one of the personal health habits discussed

in this section and obtain more information about it. Once satisfied that you
have an adequate fund of information, incorporate at least one new self-care
strategy into your life each week. For example, cook one healthy, nutritious
meal; exercise; commune with nature; get a good night’s sleep. Journal about
that experience. Engage in this strategy once weekly for one month. Then add
a second strategy each week. Keep adding one strategy to your week for four
months. Journal about how these self-care skills affect your daily life.

lar variables has made it tempting for many to avoid the outdoors when condi¬
tions are perceived as less than perfect. This leads to an alienation from the rest
of the world and from the very environment that is the natural ecology of our
species (Burns, 1998). Humans did not evolve indoors; they are potentially
closely tied to nature and have a strong relationship with it. Many people could
obtain incredible physical and emotional healing power from nature if only
they exposed themselves to it, given that “unthreatening natural environments
tend to promote faster more complete recuperation from stress than do urban
environments” (Pigram, 1993, p. 402). Health care for centuries was naturally-
based, not only in the sense of physical health, but also in the sense of mental,
emotional, and spiritual well-being. Close communion with nature was per¬
ceived as conducive to maintaining health, as well as healing in and of itself.
Natural phenomena, such as sacred sites or environments where healing has
taken place, interactions with nature such as natural rituals or bathing in nat¬
ural bodies of water, and natural medicines, such as herbs and foods, were the
primary healing and preventative forces that human beings relied on for most
of their evolutionary process (Burns, 1998).
Modern life has largely superceded humanity’s interaction with raw, nat¬
ural environments. This is an unfortunate reality given the healing power
of natural environments that can reduce stress, enhance positive affect, im¬
prove parasympathetic-nervous-system functioning, and enhance self-esteem
(Ulrich, Dimberg, and Driver, 1991). Having the knowledge that being part
of nature can be healing in and of itself gives clinicians a powerful tool for self¬
rejuvenation, relaxation, disease prevention, and healing. Spending some time
outdoors every day in as natural an environment as possible has enormous
positive consequences for mind, body, and spirit. This time outdoors does not
have to be reserved for weekends or vacations, nor should it be guided by
weather. The experience of walking in the rain can be immensely pleasurable
94 CHAPTER THREE

and healing. The silence of a remote piece of land that allows the person to
escape the hectic pace and noisy background of modern society cannot be sur¬
passed in terms of its positive effects by any therapeutic or counseling interven¬
tion in the repertoire of today’s mental-health-care providers. Availing oneself
of this incredible resource for health and healing means taking care of oneself.
Using this resource for clients is, of course, another possibility and one that is
beautifully explored in Burns’ (1998) book entitled Nature-Guided Therapy.

Attention to Relationships

Attention to relationships is as important as attention to personal health habits.

Most humans are highly social creatures who feel best if firmly embedded in
an interpersonal matrix of meaningful and sustaining relationships (cf., Kohut,
1984). There are many personal traits that can greatly facilitate positive rela¬
tionships that sustain health as opposed to creating stress. Although it is im¬
possible to outline all of these traits here, or to even come close to attempting
to teach them, a few suggestions will be outlined whose incorporation into per¬
sonal life tends to be extremely helpful. Paying careful attention and taking re¬
sponsibility in relationships can reduce stress and create a source of support
that is sustaining when work life is difficult.
The most important relationships to attend to are friendships and intimate
relationships. However, the few guidelines that follow really apply to all rela¬
tionships, even those with strangers, clients, bosses, and colleagues. To make
positive relationships happen, active work has to take place. This work is ap¬
plied to self and relationships to harmonize interactions with others. Working
on the self is the first step in creating positive relationships. Empathy, toler¬
ance, acceptance, and respectfulness are essential ingredients of healthy rela¬
tionships and largely depend on personal attitudes and self-awareness (which
will be dealt with in more detail below). Thus, working to become a better and
more tolerant person is a prerequisite to learning to respect others and to al¬
low them to be different from one’s self. It is important not to place personal
rights ahead of those of others; to be considerate of others’ needs and respect
their right to be themselves; and never to try to form anyone in one’s own im¬
age. If we treat others respectfully, they will treat us respectfully. Polite and re¬
spectful interactions reduce stress in day-to-day life, making interactions with
those in our interpersonal matrix more positive and enjoyable.
Another helpful trait that tends to keep relationships positive and sustain¬
ing is the ability to laugh at oneself. Those individuals who have learned to
laugh at themselves and their own shortcomings are rarely quick to jump to
conclusions about others and seldom place blame. They are able to put things
in perspective with the recognition that everyone makes mistakes and has flaws
that are played out in relationships. The ability to laugh at oneself, however,
 SELF-CARE SKILLS 95

Skill Development Recommendations

Recommendation 3-4 For the next inonth, keep a journal of your inter¬
personal relationships. Evaluate how you treat people and look at how you
prioritize relationships. If you are satisfied, with how you relate to others,
you are done; if you identify areas of weakness or dissatisfaction, set specific
goals about how to go about improving your relationships. Consider personal
counseling or therapy to assist you if needed.

must not be mistaken as an excuse not to change and grow; being able to laugh
at oneself is the beginning. The next step is to look at whether the situation can
be avoided in the future through self-change and growth. The ability to laugh
at oneself in and of itself often suffices to defuse potentially conflictual situa¬
tions in relationships as the other person involved will not feel attacked or
blamed.
Very similar to the concept of not taking oneself too seriously and being
able to accept ones shortcomings is the notion of defenselessness and detach¬
ment from ones personal point of view. People who are not defensive and not
overly attached to convincing everyone of their personal point of view tend to
have more positive and less conflictual relationships. It is rare that any issue is
so important that a relationship needs to be sacrificed over it. There is usually
room for compromise; everyone involved can learn to adjust their point of view
or opinion somewhat. Further, the ability to not get defensive when challenged
can serve to make interactions with others less conflictual and more collabora¬
tive or cooperative. All too often people get locked into perceiving a difference
in opinions as a personal attack, followed by the need to defend themselves and
their point of view. Learning to accept differences of opinion as the expression
of different, but equally human, ways of looking at the same situation can free
people to let go of the need to defend themselves. This does not mean that
people always have to agree with each other. It merely means that everyone
needs to recognize that they neither have to get upset nor angry if they per¬
ceive a challenge to their actions or beliefs.
One final note is necessary about relationships and their role in the lives of
mental-health-care providers. Just simply having and valuing relationships is
important as their presence appears to mediate a decrease in burnout among
clinicians! The quality of the relationships counts, of course, but first of all, they
must be in existence. The traits that were discussed above are helpful for main¬
taining relationships, but also for initiating them. Attention to building a close
circle of friends is critical, as is the forging of at least one intimate relationship.
96 CHAPTER THREE

Attending to family relationships cannot be overemphasized as this is the set¬

ting where many of us seek support first and most frequently. Relationships
help balance our lives and often ensure that we keep events around us in the
proper perspective, not overreacting to “small stuff.” There are of course many
resources and books that can easily be found in any popular bookstore to help
clinicians pay attention to this aspect of their lives.

Recreational Activities

Another highly balancing aspect to life is to pay attention to leisure and recre¬
ation. Being able to have fun and to enjoy life is often most easily accomplished
through recreational activities. The range of activities is literally infinite and the
following paragraphs will merely point out some of the possibilities. The main
lesson of this section is to attend to leisure and to learn to view it as important
and life-sustaining. Ignoring leisure for the sake of making more time for
work is not a good idea. Life is short. Who wants to die thinking, “If only I had
tried. . . .” Making time for hobbies and interests is an enjoyable way to add
spice to life and prevent boredom and burnout. It is best to make leisure skills
as different from work as possible. There are unlimited possibilities as far as
hobbies are concerned. The only limiting factors are motivation, desire, cre¬
ativity, interest, and physical capabilities. It is never too late to pick up new
hobbies or to try to acquire new skills. Hobbies can include outdoor activities
(hiking, backpacking, kayaking, skiing, gardening), introverted activities (paint¬
ing, writing poetry, composing music, playing music), sociable activities (danc¬
ing, playing music for others, leading guided hikes, joining a theater group), se¬
date activities (reading, knitting, stamp collecting), active activities (sports,
performing arts, volunteering), and many more. The most important thing for
clinicians appears to be to develop interests and hobbies outside of the mental-
health-care field.
Travel is another way of recreating and spending quality leisure time. Not
all vacations have to be lengthy or expensive. Vacations can consist of extended
weekend trips and can even be taken at home as long as work is honestly
avoided. The definition of vacation is really a broad one that is only limited by
personal imagination and preferences. The greatest vacation for some people
may be a three-day backpacking trip; for others, it may consist of two weeks in
Europe. Making vacations fit personal preferences and finances is the most
critical piece so that they do not end up creating more stress than pleasure. If
a vacation is so expensive that it subsequently requires many extra hours of
work, it may not be worthwhile. Similarly, a vacation that is so full of enter¬
tainment and activity that the traveler arrives back home feeling overwhelmed
and exhausted, did not serve its purpose fully. Striking a balance between nov-
 SELF-CARE SKILLS 97

Skill Development Recommendations

Recommendation 3-5 For the next month, keep a journal of ijour recre¬
ational pursuits. Evaluate how you spend your time and look at how you pri¬
oritize your recreational activities. If you are satisfied with how you relax and
recreate, you are done; if you identify areas of weakness or dissatisfaction, set
some goals about how to go about improving. Consider personal counseling or
therapy to assist you if needed.

elty and relaxation, excitement and meditation, learning and stress reduction is
best considered while planning a trip.
Another aspect of recreation and leisure is group memberships. This is not
for everyone, but can be extremely rewarding for more sociable types. Group
membership is best chosen away from the mental-health profession. Refer¬
ence is not made here to association membership, although that is certainly im¬
portant to professional self-care (see Brems, 2000). Reference is made instead
to making friends and acquaintances in settings that have nothing to do with
the mental-health-care profession. This type of interaction is stimulating and
exciting because it provides exposure to a broad range of healthy human be¬
ings who come together for a shared purpose or interest. These purposes or
interests can range widely, including membership in organizations such as en¬
vironmental groups, religious /spiritual groups, political groups, clubs organized
around sports or special interests, and any other interesting groupings of people
who come together on a regular basis for some joint endeavor. Some groups
also help people reach beyond themselves as they come together for a greater
cause. Such volunteer work can be life-enhancing and extremely gratifying.
Finally, also in the category of recreation, there is entertainment. This is
the leisure category of least importance, though it too should not be entirely
neglected. Entertainment can consist of artistic events, cinema, dinners out,
and similar activities. It can be an event for one or two, a family, or a whole
group of friends. Most importantly, however, entertainment does not refer to
watching TV or going shopping. Entertainment for recreation and leisure
refers to an activity that is rejuvenating, stimulating, relaxing, comforting, or
otherwise self-enhancing—not to one that is dulling, passive, or mind-numb¬
ing. Entertainment can even consist of playing board games with children or
party games with a group. In some families, get-togethers often involve games
and similar activities that make the meetings more lively, active, and enjoyable.
.

,
■
 PART

Skills to Facilitate
Communication
in Psychotherapy
and Counseling
 '

■
Attending Skills
Nonverbal
C ommunication
and Listening

When you listen to someone, you should give up all

your preconceived ideas and your subjective opinions;
you should just listen to him, just observe what his way
is. We put very little emphasis on right and wrong or
good and bad. We just see things as they are with them,
and accept them. This is how we communicate with
each other. Usually when you listen to some statement,
you hear it as a kind of echo of yourself. You are
actually listening to your own opinion. If it agrees with
your opinion you may accept it, but if it does not, you
will reject it or you may not even really hear it.
Shunryu Suzuki, 1998, p. 88

Attending skills—such a simple phrase for a complex collection of behaviors

and abilities. Attending skills are comprised of a series of complex proficiencies
that cut across the verbal and nonverbal domains of communication. Attending
represents the basis of all therapeutic encounters; without attending skills, the
establishment of therapeutic rapport is most likely difficult, if not impossible.
Attending refers to the focused attention that is placed on the other person in
an interchange between two (or more) people. It is rare that people receive the
full attention of their communication partner(s). When it does happen, they are
keenly aware and appreciative of this fact. It is rare that people place full atten¬
tion on themselves; hence, it is not surprising that most clients, and perhaps too
many clinicians, are unaware of, or inattentive to, their own metacommunica¬
tions. Clients are frequently unaware of communications that go beyond the ver¬
bal, and clinicians may forget to attend to these nonverbals. Even more impor¬
tantly, clinicians may forget to pay attention to their own internal dialogs while
listening, becoming less-than-aware listeners. It is no surprise that attending
skills, specifically, nonverbal communication and listening, need to be devel¬
oped by clinicians first and foremost in training. Nonverbal communication and
101
102 CHAPTER FOUR

listening present challenges and require a complex web of skills and knowledge
that need to become second nature to the seasoned clinician.

Nonverbal Communication

Nonverbal communication is important from two perspectives: (1) nonverbal

communication expressed by the client and picked up by the clinician and
(2) nonverbal communication used by the clinician for therapeutic goals. At¬
tending to nonverbal communication is an excellent means of gaining a clearer
understanding of clients as it opens up a major area of metacommunication.
Often nonverbals express or suggest hidden meanings and agendas or lead the
clinician in a direction of questioning that would not otherwise have been
broached. At times, nonverbals are more accurate signposts of where to take a
counseling session than is verbal communication, as they may be a less-censored
form of communication. All nonverbal communication, whether unconsciously
expressed by the client or purposefully used by the mental-health-care provider,
interacts with the verbal message being sent. The relationship between non¬
verbal communication and verbal expressions has been explored and clarified
beautifully by Knapp (1978), who identified six ways in which verbal and non¬
verbal communication can interact. These six ways not only demonstrate the
complex interplay between words and bodily expressions, but also point to the
importance of recognizing the nonverbal aspects of all communications lest
much of the meaning of an exchange be lost.

Interaction of Verbal and Nonverbal Communication

The first means of interaction is repetition. In repetition or confirmation, the
nonverbal message (such as a gesture or facial expression) repeats the obvious
verbal message. In other words, the verbal and nonverbal content of the com¬
munication is identical and thus redundant. Despite this redundancy, it tends
to be the nonverbal repetition of verbal expression that makes communication
seem alive and provides speaker and listener with a sense of connectedness. The
absence of nonverbal repetition may explain why it is more difficult to achieve
the same level of intimacy in a telephone conversation as in a personal conver¬
sation. Many nonverbal aspects of communication are lost in this medium.
The second possible interaction is contradiction. Also called denying or
confusion, this is essentially the opposite of repetition in that the nonverbal
message contradicts the verbalization. The two aspects of communication ex¬
press opposite meanings. Contradiction is an important interaction to recognize
in therapy and counseling, as clients often give mixed messages. If the clinician
is skilled in picking up contradictions, many therapeutic processes can be set in
motion through the work with these nonverbal aspects of communication, as will
 ATTENDING SKILLS 103

be elaborated upon in the chapter dealing with confrontation. Clinicians, of

course, need to avoid contradictions as they communicate incongruence or lack
of authenticity.
Third, there is substitution. In substitution, nonverbals are used to express
a response to a verbal question. In other words, in substitution, the nonverbal
response literally takes the place of a verbal reaction. Being able to read the
nonverbal response is obviously critical; otherwise, the listener and speaker will
disconnect in their interaction. Therapists and counselors need to be attuned
to clients’ nonverbal responses to questions lest they miss important infor¬
mation or deem the client nonresponsive when in actuality a response has
been given.
The fourth interaction is called complementation. In complementation
(also called strengthening), a nonverbal communication serves to elaborate a
verbalization, though as in all cases, this is not often done intentionally. The ver¬
bal and nonverbal remain congruent but the verbal message is somehow am¬
plified through the nonverbal expressions accompanying it.
The fifth interaction is referred to as emphasizing or accenting. In accent¬
ing, the nonverbal aspects of the communication emphasize or highlight certain
components of the verbalization. Accenting is helpful in determining where
the importance of a verbal message may rest by attending to where the person
places nonverbal underscoring. Being aware of accents in a clients speech will
help clinicians determine where and how to intervene by picking up clues as to
what is of utmost importance to the client. In turn, counselors can use accents
of their own to emphasize certain points to their clients.
Finally, there is regulation, which is also tellingly called control and refers
to the nonverbal processes in communication that assist the speaker and listener
in timing or pacing their interaction. These are the nonverbal clues accompa¬
nying speech that tell the involved parties when to talk, when to stop, when in¬
terest has been lost or peaked, and so forth. Regulation is an important compo¬
nent of therapeutic interaction, as the therapist needs to be aware of the client’s
clues as well as of the clinician’s own inadvertent messages. Awareness of how
clients use regulation may be particularly important in cross-cultural or cross¬
gender settings as regulation signs may differ culturally. Regulation will be dis¬
cussed in more detail below in the context of timing and in the chapter dealing
with encouragers of communication. Examples and definitions are provided in
Table 4-1 to highlight the complex and helpful interactions between verbal and
nonverbal communication.

Components of Nonverbal Communication

All nonverbal communication consists of one or more of five possible compo¬
nents, namely, physical appearance, ldnesics, paralinguistics, use of space, and
timing. Physical appearance refers to the physical body of the person, along with
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 ATTENDING SKILLS 105

clothing, grooming, and hygiene. Kinesics refers to the movements of the body
as a whole or of various body parts, such as eye contact, leg movements, hand
movements, and so forth. Paralinguistics refers to the nonverbal aspects of voice
and speech, such as volume and pitch of voice or rate and fluency of speech.
Use of space explores the use of personal and environmental space by individ¬
uals, including distances diey keep from others or positions they choose in re¬
lation to objects or other people in the same area. Timing deals with a persons
understanding and use of time, as reflected, for example, in tardiness or in tim¬
ing of certain verbalizations in a temporal context.

Physical Appearance
Clinicians attend to client factors such as height and weight, grooming and hy¬
giene, manner and style of dress, eye and hair color, complexion, level of physi¬
cal fitness, and physical attributes such as scars, bruises, physical handicaps, and
prosthetic devices. Many of these characteristics are simply descriptive, but
others are usefully evaluated with regard to their nonverbal-communication
value. For example, traits such as eye and hair color are simply noted. Height
and weight can be looked at with regard to their relationship to expected healthy
or normative ranges. Hygiene and grooming can be rated as to whether they
are appropriate given societal health standards and grooming habits. Deficien¬
cies in appearance are assessed to glean information about the adequacy of the
clients self-care skills, which in turn may help the clinician make some assess¬
ment of the clients social competence and judgment (Beutler and Berren,
1995). Mental-health-care providers need to be cautious not to allow stereo¬
typic assumptions to enter into their evaluation of a clients appearance. Aware¬
ness is necessary if a certain style of dress always evokes a particular judgment
or response in a counselor or therapist. For example, the use or nonuse of
makeup is not to be confused with proper grooming or hygiene among female
clients. Many well-groomed women choose not to wear makeup. Noting this
feature as unusual is a reflection of the clinicians bias, not the clients self-care.
Appearance of the client is not the only important factor. Appearance of
the clinician may be just as important. Clinicians need to be sensitive to the set¬
ting in which they work and need to express through their appearance that they
can adapt to and understand the clientele with which they work. For example,
wearing expensive jewelry in a mental-health clinic in a lower-socioeconomic
sector of town may lead to distance between client and therapist. Needless to
say, proper grooming and hygiene are as essential as appropriate attire. What
constitutes proper clothing, however, is less easily defined. Again, the counselor
needs to adapt to the clientele. Wearing high heels and tight skirts when work¬
ing in play therapy with children is clearly going to get in the way of therapeu¬
tic work. Wearing expensive designer suits while working with homeless people
may be in poor taste. However, wearing torn, dirty, or very revealing clothing
106 CHAPTER FOUR

may be equally inappropriate. Clearly, clinicians have to develop good judg¬

ment in deciding how to dress each morning.

Kinesics
As shown in Table 4-2, kinesics can emerge from any body part. Some of the
most important body features observed involve head, face, eyes, mouth, shoul¬
ders, arms, hands, legs, feet, and torso. Motor movement observations about
all body parts are important as they can provide a great deal of information
about a client’s state of alertness and emotionality. They can help the clinician
with diagnosis related to alertness (such as delirium and dementia) as well as
diagnosis related to psychomotor issues (for example, bipolar disorder). Motor
movement overall is often further defined as agitated, fidgety, unusual, normal,
or as including tics, tremors, or motor abnormalities. Autonomic responses are
also often included, drawing attention to physiological reactions such as rate of
breathing, blushing versus paling, or pupil dilation. All motor and facial ex¬
pressions can be assessed in terms of their congruence with verbal content of
conversation as well as the level of activity or agitation they may suggest. Any
unusual or characteristic manners and habits of a person are useful to note,
such as tics, repetitive verbalizations, or nervous gestures or laughter. Eye con¬
tact is also often considered to be an example of kinesics.
Specific meanings can be attached to particular motor expressions and eye
contact patterns. Although it is helpful to review the possibilities, clinicians
must be aware that not all clients use the same kinesics to express the same thing.
For example, unfolded arms used to gesture broadly most commonly means
that the client is open and self-disclosing. For the occasional client, however,
this same gesture may indicate evasiveness or a hiding behind histrionics. For
some clients, consistent eye contact with the clinician is desirable and expresses
a good emotional connection, whereas for others, such continual eye contact
may be disturbing or upsetting. Generally, the context in which the behavior
occurs is very helpful in making the most accurate interpretation. Cultural and
gender differences need to be attended to as well, with mental-health-care
providers noting that unique differences may exist within and between certain
groups of people. Thus, even though Table 4-2 outlines some common inter¬
pretations of a range of kinesics, the wise counselor will not mistake this table
as being definitive but will use it to glean ideas about what certain movements
may mean in certain circumstances with certain clients. The most important
thing to understand about kinesics is that clients use their bodies to express
themselves and that therapists can gain an enormous amount of information
about their clients if they bother to learn what these kinesics mean for each in¬
dividual client.
Kinesics derive additional importance from the reality that they are com¬
monly used as substitutions. In other words, not infrequently clients use their
body to respond to a clinicians question. Learning a client s manner of using
 Samples of Possible Interpretations of Common Kinesics

Feature Nonverbal Expression Possible Meaning

Eyes Direct eye contact • Attentiveness ,

• Readiness for communication
« Comfort with setting and
clinician
Lack of eye contact • Withdrawal
• Avoidance of communication
• Respect or deference
Looking down or away • Preoccupation
• Avoidance
• Concentrated thought
Fixed staring • Preoccupation
• Uptightness
• Rigidity
• Psychosis
Darting or blinking eyes • Anxiety
• Paranoia
• Excitement
• Dry contact lenses
Squinting or furrowed brow • Thoughtfulness or “aha”
experience
• Concern
• Annoyance
Teary eyes and/or tears • Sadness
• Happiness
• Frustration or anger
• Concern or fear
Dilated pupils • Alarm
• Interest
• Recent visit to eye doctor
• Under the influence of drugs
Eyes moving to and away from • Recalling a memory
eye contact • Interest

Mouth Smiling • Greeting

• Positive mood
• Avoidance or denial
Tight lips • Stress
• Anger or hostility
• Concentration
Quivering lips • Sadness or crying
• Anger
• Anxiety
Biting or chewing of lips • Anxiety
• Bad habit
Open mouth • Surprise
• Boredom or fatigue or yawning
• Having a cold if breathing
through open mouth

Facial expressions Flushed face • Embarrassment

• Anxiety
Eyes open wide and mouth • Surprise
opening • Startle response
• Sudden insight
Table 4-2 (continued)

Feature Nonverbal Expression Possible Meaning

Facial expressions Furrowed brow with tight mouth • Deep thought or concentration
(continued) • Irritation or annoyance
• Rejection of a therapist
response
Eyes looking up and mouth pursed • Memory retrieval
• Disagreement
• Thoughtfulness or pondering
of a suggestion

Head Nodding up and down • Agreement

• Listening and/or paying
attention
Shaking left to right • Disagreement
• Disapproval
Hanging • Sadness
• Hopelessness
Cocked to one side • Pondering
• Listening and/or paying
attention

Shoulders and neck Shrugging • Uncertainty or ambivalence

• Indifference or lack of caring
about something
Slouched • Sadness
• Withdrawal or shyness
• Bad posture
Raised • Self-protection
• Stretching
Neck rolls • Tension
• Stretching

Arms and hands Folded arms • Closed to contact

• Dislike or emotional distance
• Creating a barrier for self¬
protection
Trembling hands • Anxiety
• Anger
• Disease process (e.g.,
hypoglycemia, Parkinson’s)
Clenched fist or tight grasp • Anger or imminence of
acting out
• Resistance to disclosure
• Intimidation
• Bad habit
Open gesturing • Openness to disclosure
• Willingness to make contact
Stiff and/or unmoving • Anger
• Anxiety
• Reluctance or shyness
• Sore muscles
Legs and feet Crossing and uncrossing • Anxiety or nervousness
• Depression
• Self-protection
Foot tapping • Anxiety
• Impatience
Stiff and/or controlled movements • Anxiety
• Closed to contact
• Repressed attitude
• Sore muscles
 ATTENDING SKILLS 109

Feature Nonverbal Expression Possible Meaning

Body Leaning forward • Attentiveness and interest

• Openness
• Connectedness
Leaning away or back • Withdrawal
• Rejection of a clinician
verbalization \
• Relaxation or comfort
Turned to the side • Avoidance
• Fear or expectation of
rejection
• Reduced openness
Rocking or repetitive motion • Anxiety, nervousness, or worry
• Bad habit
• Developmental disorder
Habitual movement (e.g., tapping, • Concentration and/or focused
hair twirling, squirming) attention
• Boredom
• Impatience
• Anxiety or nervousness
• Bad habit
Breath Slow and deep breathing • Relaxation or attempt at
calming down
• Comfort
• Good breathing habits
Hyperventilation (overbreathing) • Anxiety or panic
• Loss of emotional control
Underbreathing • Anxiety
• Depersonalization
Short, flat, and choppy breathing • Anxiety
• Depression with crying
• Poor breathing habits

the body to respond is important for the counselor to understand each individ¬
ual fully. Similarly, ldnesics are an important means through which clients ac¬
cent their speech. Knowing how to read a client s motor expressions may there¬
fore be very helpful in recognizing where the client places the emphasis in
communication and in honing in on the topic most important to the client.
Finally, it is important to note that the use of ldnesics is not limited to cli¬
ents. Clinicians also express nonverbal information through eye contact and
body movements. Although it is important for clinicians to understand what
clients are attempting to express through ldnesics, the same cannot be assumed
about clients. Clients make assumptions about the therapists ldnesics based on
their own experience with how they express themselves nonverbally; they do
not usually attempt to understand the unique expression of the counselor.
Aware care providers adapt their personal ldnesics to the client, rather than ex¬
pecting the client to learn the therapist s unique way of using kinesics. This re¬
quires self-awareness on the clinicians’ part about how they come across to the
110 CHAPTER FOUR

client and about how the client interprets their nonverbal behavior. One ex¬
ample may be the reduction of eye contact with clients who are clearly un¬
comfortable with a clinician’s usual amount and maintenance of eye contact.
Another example may be increased use of hand gestures by the clinician with
clients who are very reliant on body signals for accenting speech, to help the
client discern more easily where the counselor places emphasis.

Paralinguistics
Nonverbal or metacommunication aspects related to voice and speech have
great communication value. Clinicians direct their attention to several aspects
of speech, including voice volume and pitch, speech fluency, rate of speech,
and pattern of speech. With regard to voice volume and pitch, the client can
be better understood if the therapist attends to how high or low the client s vol¬
ume is when speaking of various contents, and whether volume or inflection
changes depending on topic. Very high volume may relate to anger, whereas
very low volume may indicate sadness. A high-pitched voice may suggest anxi¬
ety; changes in inflection may direct attention to particularly emotional topics.
Speech fluency is explored with regard to the intrusion of stuttering or similar
speech errors, as well as jerky speech that changes in clarity and fluency across
topics. For example, sudden hesitations in speech may indicate anxiety about a
topic or second thoughts about self-disclosure. Stuttering that is confined to
times when particular topics are broached may give evidence to discomfort or
agitation. Speech errors, such as wrong word choice or inability to think of the
right word, may suggest anxiety or resistance.
Rate of speech refers to the speed with which the client communicates. It
could theoretically be evaluated by looking at the number of words spoken per
minute. Most concretely, rate ranges from slow to fast. Rate of speech varies
greatly across cultural groups and geographic settings. Thus, interpretative
value is derived not from rate of speech in and of itself, but rather from changes
in the rate of speech of a given client. In other words, a client who always speaks
fast is not perceived as particularly anxious when speech is quick. However, if
a client who usually speaks rather slowly suddenly speeds up the rate of speech,
such an interpretation is possible. Similarly, if a client who usually speaks at a
high rate of word production suddenly slows down and cannot seem to speak
more than a few words a minute, the possibility of depression may need to be
explored. If the rate of speech always appears unusual, the clinician will evalu¬
ate the rate itself. For example, a client who chronically underproduces (that is,
has an unusually slowed rate of speech) may be severely depressed; a client
who chronically overproduces may be agitated or even manic. Finding out if
rate of speech changed over the clients lifetime would be important informa¬
tion in this context, again pointing to the fact that it is indeed the change in rate
 ATTENDING SKILLS 111

of speech that is important, but extending the time frame for this temporal
exploration.
Patterns of speech refer to any additional changes in speech not captured
by the definitions about voice and speech given so far. They draw the clinicians
attention to aspects such as silences, pressure (very driven speech that is not
only fast in rate but also in thought production), geographic or ethnic accents,
or unusual expressions (such as voice breaking, sighing, or gasping breaths that
interfere with speech). Sudden silences may signal despair or confusion, or
may indicate that clients are digesting an important insight and are collecting
their thoughts. Pressure in speech and thought production most commonly
reflects agitation of some sort, whether due to anxiety, anger, or excitement.
Gasping for breath may signal the onset of panic; a breaking voice may indicate
sudden sadness; sighing may indicate discouragement or relief.
It is important to note that, as was true for the interpretation of ldnesics,
paralinguistics are best understood and interpreted within the individual
context of each client. Although a few generic observations were provided
above, the most accurate understanding is derived from carefully observing
each client and recognizing the most common or usual pattern of paralin-
guistic expression. Any deviations from the established (baseline) pattern can
then be interpreted and used to enhance the understanding of the verbal
communication. Voice and speech are also usefully observed with regard to
their value in accenting or complementing verbal content. Speech and voice
accents can guide the clinician to the most important component of a client s
communication and may help the counselor recognize the depth of a clients
expression.
The self-aware clinician uses vocal qualities in communicating effectively
with a given client. The practice of consciously using paralinguistics for com¬
plementation and accenting gives the clinician an added edge in making an im¬
portant message heard. Further, mental-health-care providers need to be sen¬
sitive to the fact that clients may have specific personal reactions to a given
clinicians unique way of using voice or speech. Adapting voice quality to match
a particular client can be useful in connecting with the client in the early at¬
tempts at rapport. However, at times choosing a speech pattern or rate that is
very different from the client s may be a useful therapeutic intervention that
models a means for calming or relaxing. For example, if a therapist works with a
client from an ethnic group that has a much slower rate of speech than that of
the clinician, it will behoove the clinician to slow down the rate of speech to
match that of the client. If on the other hand, a client has an extremely high rate
of speech due to anxiety or agitation, the clinician would model the opposite of
the client s rate of speech to help the client gain a modicum of relaxation and
calmness. The targeted use of paralinguistics by the therapist can be a power¬
ful therapeutic intervention in its own right.
112 OH U'Tb'H KOI' H

Use of Space
Obserxing how clients use personal and environmental space is often a useful
wax of better understanding them. Phe two most important aspects of space
utilization are distance and position. Distance refers to the amount of personal
space a client appears to require. Some clients need signifieantlx more distance
from the therapist than others in order to feel comfortable in a counseling set¬
ting. The\ max go to great lengths to mox e their chairs as far .m ax as possible
from the counselor. Other clients max feel most comfortable it the distance be¬
tween them and their clinician is at an absolute minimum. Although cultural
differences exist that max make the need for personal space somew hat predict¬
able. it is generallv best just to observe the personal-space needs of each client
and then attempt to honor and respect those needs, (bender differences max
be observed as w ell. Difficultx can arise if the personal-space needs of the cli¬
ent and the clinician conflict signifieantlx . For example, if a client has a need to
be closer to the therapist than the therapist is comfortable with, the clinician's
unconscious reaction of moxing a chair a wax from the client max Iv interpreted
as rejection or aloofness. Thus, clinicians need to be axxure of the client's space
needs and trv to accommodate these as much as possible. The size of a therapx
room may have an impact on the space needs of a client and clinician. A small
office, overloaded with furniture or other items, max make it impossible for the
client to settle into a distance from the clinician that feels comfortable. Thera¬
pists who have to use a small space in w hich to do their work need to think about
how to set up chairs and furniture to maximize the use of their limited space.
Adding features to the room that create an illusion of more space such as mir¬
rors' may be of assistance. Also related to distance between the counselor and
the client is the issue of touch. Touch closes all distance between two indixid-
uals. Although this can be a x erx human and earing reaction, reaching out and
touching a client can also carry negatixe consequences. Not all clients appreci¬
ate touch and some max misinterpret it. The best rule of thumb for beginning
clinicians is to refrain from the impulse to touch, especially early on in the w ork
with a gix en client. It' the clinician does not want to retrain from touch, the
next-best solution is to ask the client if touch is acceptable. If a client indicates
any hint of reticence to this request, the clinicianw ould xiolate the client's per¬
sonal boundaries through touch, a disrespectful and perhaps frightening mox e.
The second aspect of space utilization, positioning, is equally important to
understand both from the client's perspective and from the therapist's. Position¬
ing refers to the position a client or clinician chooses relative to other objects
in the counseling room. Again, cultural and gender preferences max exist, but
individual differences .ire the most important variation to obserxv. Positioning
is expressed by the clinician in the layout of the therapx office. A therapx office
that is set up so that a desk is positioned between client and clinician will com¬
municate something very different from a therapx room in which the client's
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114 CHAPTER FOUR

amples of behavior given here (such as bringing up important material late in

the session or coming late lor counseling) means missing important opportu¬
nities for process comments. This issue will be revisited in a later chapter.

Helpful Hints for Nonverbal Communication

The therapy or counseling process contains a wealth of nonverbal or meta¬
communication, expressed by both client and clinician. Understanding non¬
verbal communication as expressed by the client and using nonverbal commu¬
nication consciously for therapeutic goals will greatly enhance a clinicians
therapeutic skills. A few potential nonverbal pitfalls that are best avoided by
mental-health-care providers are illustrated in Table 4-3. These nonverbal ex¬
pressions tend to put clients off and may lead them to feel unheard and mis¬
understood. Being self-aware in general has been discussed as an important
counselor trait; being self-aware about unconscious nonverbal self-expression
cannot be overemphasized with regard to its importance in establishing and re¬
taining therapeutic rapport. In addition to avoiding the nonverbal pitfalls out¬
lined in Table 4-3, three important concepts facilitate good nonverbal commu¬
nication and thus therapeutic rapport, namely, congruence, sensitivity, and
synchrony.
Congruence refers to the clinicians efforts to keep personal verbal and non¬
verbal expressions in line with each other. Achieving congruence between what
a counselor says and does is critical to good therapeutic rapport. Clients are
easily confused by incongruence in the clinician and may perceive it, rightly so,
as a recapitulation of conflicts or problems they have encountered with others in
their lives. Congruence can be practiced; some hints about how to maintain con¬
gruence between verbal and nonverbal expression are outlined in Table 4-4.
Sensitivity refers to a mental-health-care provider s ability to receive and
understand the clients nonverbal communications. Learning how to interpret
the ldnesics and paralinguistics of each individual client is a critical component
of sensitivity. Recognizing how the clients nonverbal and verbal communi¬
cations interact (repetition, contradiction, substitution, complementation, ac¬
centing, and regulation) will add depth to the counselors understanding of the
client and will facilitate therapeutic responsiveness. Sensitivity also refers to re¬
specting a clients personal-space needs and Creating an environment that
makes it possible for clients to feel comfortable and heard.
Finally, synchrony refers to the clinicians ability to match or oppose the cli¬
ent s nonverbal expressions as therapeutically indicated. Matching is used when
the therapist views the clients nonverbal communication as a means of join¬
ing with the client and creating an empathic atmosphere. For example, match¬
ing a clients lowered voice and lowered rate of speech when the client talks
about a sad event will help the client feel heard and understood. Contrarily,
 TABLE

Sample Pitfalls in Nonverbal Expression

Nonverbal Pitfall of the Clinician Possible Reactions of the Client

f /bev, /e pr /'- se closer ess a’ outset Feeling crov/ded or overwhelmed; mis-

of treatment ur derstandmg the behavior as seductive¬
ness by the clinician
E/cess /e r/ ys ce <3 star ce at outset Feeling rejected or at least not accepted;
of treatment peme /ir g the clinician as arrogant or
staridoffish
Distar o ng movement of body after a c ent Fee rig , zdged. rejected, or misunderstood;
express on perce ving the clinician as judgmental or
reactive for personal reasons
Atoaent e/e contact Feeling gnored, not feeling cared for;
perce / ng the clinician as shy or insecure
J **ery or moons stent e/e cor.tact ‘ Jot fee ng atter ded to, feeling perceived as
nor ng percei /mg the c ir dan as distracted
Excess; /e e/e contact Feeling under scrutiny, feeling uncomfortable
arid intruded jpor; percei/ing the clinician
as intrusive
Oee* - g ca" em out of objecta ("e g deer Feeling rejected, not feeling accepted, feei¬
geo eng peno) ng jr mportant; perceiving the clinician as
aloof
'o/ gr >e-' * fac e express or c Confusior feel rg misunderstood, feeling
p seated, feel ng lied to; percei /ing the
c mic an as inconsistent or incongruent
noo' g' >e-' • gev ,res Confusion, feeling misunderstood, feeling
placated fee ng eo to; perceiving the clini¬
cian as inconsistent or incongruent
D e*ar c ' g ‘ac a e/precc or c 'cored 7/ Fee- ng ur important, feeling percei /ed as
/a/r ng ack of cor e ver ’ eye contact etc./ no' ng not be ng accepted, no*, feeling liked;
perce / rig the clinician as emotionall/ absent
D va' c r, g cod/ rnoverrer ts fcrossed Fee ng rejected, not feeling heard, not feeling
arms or egc cc/c'g ego oha'moved ked not fee1' g accepted: percei /ing the
a//a/ etc.) c:-r 0 an as emotionally rejecting or cold
0 vmac r g rr er r er 0" c fe g 'n r ng ha' Fee r g perce /ed as boring, not feeling
pia/irg /. •' a" earrog scratch 'g etc ; amended to, fee ing perce:/ed as uninterest-
ing; perce. ving the clinician as anxious or
mattenti /e
Excess /ef/ o jo /o ce or rap d speech Fee ng bossed around, feeling overwhelmed,
being g /en ad vice or tola what to do; per-
cei/ing the clinician as angry or hostile
Excess /e / o/r vo ce or 0 o//ed 'ate Feelir g insecure about the value of treatment;
of speecr perceiving the clinician as unsure of self
-- ga o' -a ?. c‘ oceec' poo.5 Fee ng perce /ed as incompetent, feeling
te g . oterrupt eg c ent) perce /ed as unimportant, not feeling heard;
percei/ ng the clinic an as incompetent or
unempathic
E/oeco /e / ' g' energy e/e fe.g fidgetrg. Fee 'g perce /ed as unintelligent, feei ng
cc / o' g tax ng fast; peme /eo as boring; percei/mg the clinician
as impatient
E/ceoc/e / 0//energy le/e 'eg oio/red Feeling ur mportant. feeling perceived as
ps/cr orriotcr " o/ement 0 o//ed speech / bor- g percei /ing the clinician as depressed
or Incompetent
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 ATTENDING SKILLS 117

Skill Development Recommendations

Recommendation 4-1 From now on, while engaging in conversations with

family members and friends, begin to focus on their nonverbal expressions of
emotions. Note facial features, body posture, gestures, and other bodily clues
about how the person with whom you are speaking may be feeling. Do not al¬
low the verbal content to get in the way of your nonverbal listening. Pay care¬
ful attention to body language, even if it appears inconsistent with what is be¬
ing said. Begin to notice if different people have different ways of expressing
the same message.

Recommendation 4-2 From now on, when you are in a public place with
extra time on your hands, become a people watcher. Without hearing their
conversations, pay attention to how people express themselves. Try to guess
what emotions they are expressing by how they hold their bodies, faces,
hands, and so forth.

when the therapist opposes the client s excessive rate of speech and volume of
voice used in a fit of anger, this may help the client get the out-of-control affect
under control. Matching of a clients nonverbal expression can occur cross-
modally as well. For example, a lowered volume of voice may be matched by the
clinician with a lesser production of speech; a high rate of speech production
by the client may be cross-modally matched by the therapist who sits up straight
and intently. The idea is to match the intensity and quality of the clients ex¬
pression in some form, whether by imitating the same nonverbal feature of
self-expression or by using the same intensity or quality in another nonverbal
modality.

Listening Skills

The second aspect of attending skills is listening. Listening with any degree of
accuracy is easiest if the listener focuses attention fully on the speaker. It is fur¬
ther facilitated by the listener s self-awareness, developed through the practice
of fully attending to and learning about personal internal processes and reac¬
tions in all sorts of situations and circumstances. For listening to take place in
therapy or counseling, the clinician and environment are best consciously and
118 CHAPTER FOUR

psychologically prepared lor the therapeutic exchange. This means, but may
not be limited to,

• putting aside personal concerns and worries for the extent of the therapy
or counseling session
• being fully awake, alert, and focused (that is, not sleepy, fatigued, or sick)
• allowing oneself not to be distracted away from the client even by the
most enticing or curious environmental or internal occurrences
• creating an environment that is conducive to a therapeutic exchange
(quiet, confidential, sufficiently spacious)
• being sufficiently self-aware to be able to be open to the client s
communications
• communicating attentiveness via kinesics (leaning forward, being relaxed
and open, and making appropriate eye contact)
• having knowledge of cultural and gender preferences regarding situations
that involve the exchange of personal information
• being sufficiently aware of individual differences to adapt rules of the
game to the individual needs and preferences of each client
• being aware of and attempting to remove all personal roadblocks to
communication
Listening in a therapeutic manner means taking in the client s whole story.
The first prerequisite to such complete and active listening is the ability to al¬
low a client to speak uninterruptedly, even if the client takes breaks or pauses
between words, sentences, or thoughts. Learning not to speak prematurely, in
essence interrupting the client s stream of thought, is one of the most important
listening skills. Most people have a tendency to take even the briefest pause as
an indication that it is their turn to talk. However, in a therapeutic setting, clini¬
cians have to learn that this is not always the case; it is best for counselors to
wait until they are certain that the client has finished before jumping in with a
question, comment, or thought. Pauses or silences vary in length from client to
client, with gender and cultural differences often being noted. Adapting to a cli¬
ents speed and use of breaks is the beginning of good listening. Listening to the
clients whole story also means taking in all related affects, thoughts, and be¬
haviors in addition to any content that is volunteered by the client. Recogniz¬
ing the greater context of a client s verbalization and looking for emphasis and
meaning are excellent means of assuring good and comprehensive listening. To
be able to listen in this manner, certain skills and awareness are necessary. One
of the most important issues for beginning clinicians is to learn to recognize
barriers to active listening, also referred to as roadblocks.

Roadblocks to Listening
Listening can be interfered with if clinicians are unaware of distortions and in¬
terpretations they bring to the therapeutic encounter. The first step in develop-
 ATTENDING SKILLS 119

•ing accurate active-listening skills is the exploration of a variety of roadblocks

or distortions that interfere with effective hearing (Egan, 1994). Six important
roadblocks described by Egan are inadequate listening, evaluative listening, fil¬
tered or selective listening, fact-centered listening, rehearsing-while-listening,
and sympathetic listening.
A clinician who is preoccupied with personal worries or needs will evi¬
dence inadequate listening due to the inability to redirect the focus of atten¬
tion to the client. Attention is directed to the self and its worries and needs and
distracted away from the client. Hearing a client in this frame of mind is almost
impossible as it is flavored so directly by the internal needs of the counselor.
Not surprisingly, the therapist does not receive everything the client is saying
and mis-hears some of what is voiced. As importantly, attention to kinesics and
paralinguistics is distracted and interpretation of these phenomena is inade¬
quate at best, absent at worst.
The clinician who makes judgments about what the client is saying as the
client is saying it engages in evaluative listening. In this form of listening, ob¬
jectivity is lost because the mental-health-care provider is making decisions
about how to evaluate what the client is saying based on judgment and preju¬
dice. Such evaluation of the client not only misses the point of therapeutic
open-mindedness, but it also tends to lead to advice-giving. The clinician who
listens evaluatively tends to think of “better solutions” or reactions than those
described by the client. The judgmental attitude about the client’s choices then
tends to come through in the clinician’s responses and may be perceived by the
client as exactly what it is: evaluative and judgmental.
Some mental-health-care providers hear what they expect to hear or want
to hear. They enter the counseling session with certain preconceived notions
about the client. These preconceived notions may arise from the clients physi¬
cal appearance (sloppy dress perhaps leading to the notion that the client is a
“slob”), gender (the clinician holds certain sex-role stereotypes that are pro¬
jected onto the client), ethnicity (the counselor has racial biases or prejudices
that emerge), presenting concern (a clinicians belief that all clients with suici¬
dal history are borderline), and so forth. Snap judgments and prejudices in¬
trude on the exchange with the client and result in selective or filtered, listen¬
ing. Care providers make the initial assessment of the client, then hear what
they expected to hear. For example, a client with a history of suicide may be
perceived as fickle, inconsistent in relationships, unclear about future career
goals, emotionally labile, and unintegrated. It is certainly possible to frame most
clients’ stories in such a negative light if that is the expectation that is brought
to the session by the clinician. Filtered or selective listening may lead the ther¬
apist to hone in on the most pathological aspects of the story and to miss the
healthy ones.
When clients come to treatment, they express themselves verbally and
nonverbally as discussed previously. They also tell their stories in at least two
120 CHAPTER FOUR

ways: factual and emotional. A clinician who falls into the trap offact-centered
listening will not hear the clients emotional story, and will miss much of the
clients metacommunication. Only information or overt content is received; la¬
tent, nonverbal, emotional, or personal content that is less obvious is missed.
The counselor forgets to listen to all aspects of the client and gets caught up in
facts. This creates an experience-distant exchange between clinician and client
that will be perceived by the client as unempathic, perhaps even intrusive. It is
often the case that fact-centered listening leads to excessive questioning of the
client by the clinician, a process called shotgunning (to be explained further in
the chapter on questions).
Some therapists, especially those with little experience, are so worried
about how to respond to a client that, instead of simply listening, they carry on
an internal dialogue formulating what to say next. This preoccupation with
finding the perfect response to the client ironically gets in the way of making
even a halfway-decent response because in the process of dialoging internally,
the client is not heard. This kind of rehearsing-while-listening suggests anxiety
on the clinicians part, a reality that will be hard to hide from the client. It is
preferable to give the client full attention and make a less-than-eloquent re¬
mark in response that is at least on target if not beautifully phrased. A nice flow
of thought and eloquence in expression will develop with practice and can only
be effective if it is to the point and reflects a keen understanding of what the cli¬
ent has said and expressed nonverbally. Rehearsed responses rarely are on tar¬
get and leave the client feeling misunderstood and not individually responded
to or respected.
Sympathetic listening is the kind of listening people engage in in social set¬
tings and conversation. On the surface, it may appear to be a fine way of inter¬
acting with a client because the counselor responds emotionally and compas¬
sionately, but it is not really a therapeutic exchange. The therapist who listens
sympathetically gets caught up in the clients story (either its content or its
emotional overtones) and overidentifies with the client. Before long, such cli¬
nicians feel just as bad as their clients and will have the strong desire to make
things better for the client (if only to feel better themselves). Objectivity and
therapeutic distance are lost as the counselor is in the middle of the story with
the client. Both get caught up in the quagmire of the story and lose sight of how
to extract themselves from it. Sympathetic listening does not always have to
happen to this full extent. Partial sympathetic listening may reduce a clinicians
objectivity, but some distance may be maintained that allows for an appropri¬
ate response. Sympathetic listening is hard on the counselor in the long run be¬
cause it is emotionally draining.
The roadblocks to listening are summarized in Table 4-5. It is important
for novice clinicians to be very familiar with them, since these distortions tend
to be more prevalent early in professional life. The nervousness and self-
 ATTENDING SKILLS 121

Roadblocks to Effective Listening

Roadblocks Definitions Potential Consequences

Inadequate listening Clinician is inattentive or pre¬ Client will not feel heard; clini¬
occupied with personal worries cian misses important aspects
or need states of the client’s communication
Evaluative listening Clinician makes judgments Client feels judged and mis¬
about what is heard and thus understood; clinician tends to
loses objectivity feel superior and to give advice
Filtered or selective Clinicians hear what they expect Client feels misunderstood and
listening or want to hear based on pre¬ misrepresented; clinician fails
conceived notions due to pre¬ to hear the client’s true mes¬
judice, bias, or stereotypes sage and misrepresents (often
pathologizes) the client’s state
of being
Fact-centered listening Clinician only listens to overt Client perceives clinician as
content (verbal information) and experience-distant, non-
misses the latent or covert con¬ empathic, and intrusive; clini¬
tent (personal and emotional cian tends to overuse ques¬
message) tions and shotguns the client

Rehearsing-while- Clinician is preoccupied with Client feels misunderstood and

listening how to respond to the client, disrespected and perceives
formulating responses while the the clinician as anxious; clini¬
client is speaking and thus not cian misses essential aspects
attending fully of conversation and makes
comments that are well-
phrased but off-target

Sympathetic listening Clinician gets caught up in the Client may feel heard but not
client’s story (content or emotion) helped; clinician loses objec¬
and overidentifies with the client tivity and distance leading to
ineffectiveness and burnout

preoccupation of novice clinicians as they see their first clients are perfect
breeding grounds for listening roadblocks. Being aware of them helps identify
them as they occur and allows the clinician to make changes in listening stance.

Essential Skills for Good Listening

There are other preparations to ensure accurate active listening beyond aware¬
ness of roadblocks. First, and perhaps most importantly, clinicians learn to fo¬
cus their attention in two ways: on the client and on the clinicians immediate
personal reactions to the client. This way of focusing attention takes some prac¬
tice but can be achieved. Second, accurate listening is predicated on the clini¬
cians ability to hear and process not only overt content (information expressed
122 CHAPTER FOUR

verbally) but also latent content (metacommunications expressed nonverbally

and symbolic meanings of verbal expressions).
Focused attention to the client develops with greater practice and ease in
therapeutic communication. Early in a clinicians experience, anxiety about the
therapeutic exchange leads to occasional inattention and self-focus. As the care
provider relaxes and becomes more familiar with therapeutic work, focused at¬
tention becomes second nature.
Focusing attention on a communication partner can be practiced in any
setting. Allowing others to speak without interrupting, observing their body lan¬
guage while they express themselves, and practicing patience in responding are
excellent means of enhancing focused attention. This practice can occur with
anyone and often is much appreciated by friends and family of the budding cli¬
nician. Focusing attention on the communication partner means taking in every
aspect of that person and developing observation skills. Consciously watching
communication partners (without making them self-conscious by being obvi¬
ous about this observation) can be helpful in beginning to learn body language.
Making the communication partner the most important focus of the moment is
key to turning one’s attention to that person completely and skillfully. Clinicians
can practice focused attention by listening to tiieir own feelings and thoughts
whenever they encounter a novel or challenging exchange. Setting time aside
each day to listen to the self (emotions and thought) can be another useful
endeavor and is very similar to meditation practice. Focused self-inspection
teaches focused attention and increases self-awareness. While with a client,
these attention skills can then be practiced by making the client the most im¬
portant issue in the room. Focused attention skills—listening fully and with
conscious awareness, observing carefully but not obviously, and monitoring
personal reactions silently but cautiously—lead to clear hearing and openness
to receiving all messages sent by the client.
Processing and understanding overt and latent communication represent
the essence of the second important aspect of good listening skills. The ability
not only to receive all messages sent but also to understand them requires at
least two sets of skills. The counselor needs to be able to understand nonverbal
communication correctly, as discussed earlier. Additionally, the therapist needs
to be able to read between the verbal lines of the client, learning recognition
of incongruence and patterns as well as awareness of metaphor and symbolism.
Recognition of incongruence will be addressed in the chapter dealing with con¬
frontation. Suffice it to say here that active listening means listening with such
alertness and focused attention that contradictions expressed by the client that
are subtle and prone to being missed in casual conversation are noticed by the
clinician. Such subtle contradictions refer to incongruence between verbal and
nonverbal communications, as for example in the client who smiles broadly
while talking about a divorce that was very acrimonious. Good active listening
 ATTENDING SKILLS 123

would imply awareness on die counselor’s part that the smile did not fit with
the verbal content of the message. Incongruence can also occur between two
nonverbal modalities of expression. For example, a client who speaks about de¬
pression may employ congruent paralinguistics in that speech is slowed and
volume of voice is low with few inflections or emphases. However, as the client
is speaking, lanesics may tell a different story, perhaps one of anger as the hand
is pounding the client’s leg and crossed legs are kicking the foot of the upper
leg. A therapist who listens actively, that is, with full focused attention, notes
the inconsistency between speech and kinesics and becomes more fully aware
of the client’s whole story.
Incongruence can be expressed in many other ways, such as between a
client’s affect and thought, affect and behaviors, thought and behaviors, or
among all three. Again, how to deal with this recognition will be discussed later;
for now, the clinician just needs to be concerned with learning to recognize
such patterns. Careful active listening also helps the clinician recognize pat¬
terns and themes expressed by the client. Patterns refers to repetitive affects
or behaviors that the client tends to evidence often or falls back upon in times
of stress and challenge. Themes, on the other hand, refers to consistent sets of
ideas, beliefs, or notions the client holds about life, self, or others. Such themes
or schemas can affect or flavor how a client perceives the world and can help
the clinician recognize why and how clients react in certain ways in certain sit¬
uations. Working with patterns and themes becomes important as the coun¬
selor begins to work in the realm of cognitions. Recognizing themes and pat¬
terns, however, is a prerequisite of such cognitive intervention and is a direct
outgrowth of carefully focused attention and listening.
A final component of active listening is sensitivity to metaphor and sym¬
bolism. Human beings think and express themselves in complex and symbolic
ways. To understand another person fully, it is important to learn that person’s
way of using language. Metaphors and symbolism function much like nonver¬
bal communication in that they are unique to each individual and are generally
used in an unconscious manner. Deciphering metaphors or understanding
symbolic meanings may sound like a daunting task. However, this is not the case.
Clinicians usually see clients in a larger context. This context helps give direc¬
tion about the underlying meaning of a client’s symbolic communication. Study¬
ing dictionaries of symbolism and metaphor is not generally helpful because
even though some general statements can be made, there is no guarantee that
an individual client will use a given symbol or metaphor in this general or pre¬
dictable manner. It is much preferable to learn the symbols and metaphors a
client uses and to communicate with the client around these chosen modes of in¬
direct expression. Once a client’s metaphorical way of self-expression is under¬
stood, listening becomes more accurate and communication becomes quicker
and easier. For example, if a client talks about a favorite TV show, this exchange
124 CHAPTER FOUR

Skill Development Recommendations

Recommendation 4-3 For the next week, listen carefully to the conversa¬
tion styles of others. Attempt to identify their listening pitfalls. Note the con¬
sequences of these pitfalls. Do not share your insights as the point of this exer¬
cise is not to criticize others, but to begin to gain awareness of how pitfalls
man ifest. It is easier to begi n identification of listening pitfalls in the conversa¬
tions of others first; then it will be easier to identify them in your own listening.

Recommendation 4-4 After having observed others’ listening pitfalls, be¬

gin to observe yourself in conversations with other people. Try to evaluate
honestly how you listen. Pay attention to whether you have any listening pit-
falls that get in the way of open and attentive hearing. As you identify your
primary pitfalls, make action plans about how to eliminate them.

Recommendation 4-5 Practice focused attention to people by practicing

with friends and family. Apply all the skills listed in Table 4-6 to your day-to-
day conversations with people you know well. Do you notice any changes in
responses? Are people aware of what you are doing? How do they feel about
it? How do you feel in these conversations? Are you learning more about
these people than you used to?

could be perceived as evasiveness or resistance, or the clinician could try to

understand the symbolism of the show. This can be done by asking the client
questions about what the different characters mean to the client and how the
client understands the plot of the show. Thus, much may be learned about the
clients beliefs about the world (themes) and about how the client feels and be¬
haves in response (patterns).
Active listening means coming to understand clients through focused at¬
tention and concentration with the goal of making them and their communica¬
tion the most important component of the human exchange that is therapy or
counseling. The skills outlined here and a few additional simple (but not sim¬
plistic) hints or recommendations that tend to be helpful are summarized in
Table 4-6. The application of these skills and their careful and continuous prac¬
tice will facilitate therapeutic rapport and useful clinical work.
It is important to note that no clinician is always fully focused and aware.
All mental-health-care providers have momentary lapses and preoccupations.
Humans are incapable of perfection in any area of behavior, and clinicians need
to accept that they will fail at times and make mistakes. There is nothing wrong
with that as long as the failure is recognized and acknowledged. The novice
 ATTENDING SKILLS 125

Helpful Hints for Accurate Active Listening

1. Make the client the focal center of attention in the therapeutic exchange
2. Be aware of personal reactions and their implications for, or impact on, the communica¬
tion process between clinician and client
3. Listen not only to what but also to how something is said, that is, attend to content and
paralinguistics
4. Pay focused attention to nonverbal communications such as kinesics, paralinguistics, use
of space, timing, and physical appearance
5. Recognize the relationship between the client’s verbal and nonverbal expressions (i.e.,
repetition, contradiction, substitution, complementation, accenting, and regulation)
6. Allow for appropriate silences and pauses, respecting and honoring the client’s needs for
breaks or bridges in a verbal exchange
7. Instead of interrupting, allow clients to finish their sentences and thoughts, being sensitive
to individual differences in length of pauses between words and thoughts
8. Listen to the whole story, paying focused attention to content, affect, behavior, thoughts,
context, meaning, and emphasis
9. Avoid all roadblocks to listening (i.e., inadequate listening, evaluative listening, filtered lis¬
tening, fact-centered listening, rehearsing-while-listening, and sympathetic listening)
10. Learn to read between the lines, becoming familiar with each client’s unique use of
metaphors and symbolism
11. Listen for themes and patterns in the client’s verbal (overt) and nonverbal (latent) commu¬
nication
12. Develop awareness of incongruence in the client expressions, recognizing incongruence
between:
• Verbal and nonverbal communications
• One modality of nonverbal communication and another modality of nonverbal expres¬
sion (e.g., kinesics versus paralinguistics)
• Thoughts and feelings
• Thoughts and actions
• Feelings and actions
• Feelings, thoughts, and actions

counselor learning these skills can relax in the knowledge that even seasoned
clinicians wall “screw up” at times. What will distinguish the successful and em-
pathic therapist from the unsuccessful one is the recognition and awareness of
mistakes and the willingness to admit to them, explore them, and turn them
into learning opportunities.
Questions CHAPTER

to Encourage
Communication

Effective inquiry increases the likelihood that the

patient will experience the therapist s comments as an
invitation to explore rather than take them as a
challenge to be warded off or as a signal to hide.
P L. Wachtel, 1993, p. 88

Questions play a large role in therapy and counseling. They are no doubt one
of the most used and useful interventions available to clinicians. Questions
have a large range of purposes and applications and the following list outlines
only the most obvious:

• questions initiate and dominate the intake interview

• questions are used to begin or open individual sessions
• questions are a means of facilitating communication
• questions motivate self-disclosure
• questions can serve to expand the focus of an interaction
• questions can be used to elaborate on a given topic
• questions elicit specifics about given topic areas
• questions enrich the information volunteered by the client
• questions can be used to shift to a new topic area
• questions can serve purposes of assessment
• questions assist with making diagnostic decisions
• questions are useful during crisis management
• questions can help point out patterns
• questions can create meaning and insight in the client
• questions can enhance a clients self-awareness
• questions can be used to guide the client toward problem solving

Despite this diversity of purposes and applications, there are essentially only
three types of questions: opening or open-ended questions, systematic inquiry,
and clarifying questions. The former two categories of questions are of primary
126
 QUESTIONS TO ENCOURAGE COMMUNICATION 127

interest in this chapter as they are specifically designed to facilitate communi¬

cation and client self-disclosure. Clarifying questions, on the other hand, while
also enhancing communication and self-disclosure, primarily have the purpose
of clarifying meaning or interpreting an event, relationship, behavior, affect, or
cognition for the client. They are focused toward the creation of cognitive in¬
sight or self-awareness. As such, clarifying questions will be covered in detail
in the cognitive chapters. The focus of this chapter will be on opening or open-
ended questions and systematic inquiry. However, the many cautions and
guidelines provided in this chapter hold true and apply for all three types of
questions. To compare and contrast the three types of questions, Table 5-1 re¬
veals their respective purposes and applications.
As is evident from Table 5-1, open-ended questions are used largely to help
a client continue on a path of self-disclosure. They essentially pursue the client s
agenda, at least initially, by asking for more detail about a topic area originally
broached by the client. They reflect a mixture of client and clinician agenda, as
the clinician is the person who chooses in which direction to take the ques¬
tioning, while staying within the content area chosen by the client. Occasion¬
ally, clinicians may choose to switch focus, redirecting clients with open-ended
questions to the exploration of a new, though related, issue. This exploration of
a new topic area is related to the original content and reflects the clinician’s de¬
cision that a slight shift in focus is therapeutically useful and necessary. This
shift, however, imposes a new agenda or goal and reflects the counselor s pref¬
erence and area of curiosity.
Systematic inquiry is a useful tool for gathering vast amounts of informa¬
tion from a client. In systematic inquiry, the clinician generally chooses the
content or topic area, unlike open-ended questions, where the original topic
comes from the client. Systematic inquiry is used early on in treatment, when
the mental-health-care provider collects data about the client for purposes of
assessment, treatment planning, and diagnosis. Systematic inquiry elicits lots
of information quickly and systematically, as the label suggests. Often clinicians
have a clear sequence in mind, which they pursue in collecting information,
making systematic inquiry similar to a structured interview. This comparison,
while apt, should not be overly emphasized as structured interviews, being
formal and standardized, do not allow a clinician to deviate from the predeter¬
mined structure. Systematic inquiry, while having an equally structured agenda,
allows the clinician to pursue the agenda flexibly and caringly, with rapport tak¬
ing priority over data collection. The most common example of a systematic
inquiry is the standard intake interview that inquires about a range of client
history. Less common examples include questioning for purposes of suicide, vi¬
olence, child abuse, and other crisis assessments. In all of these instances, the
clinician has a certain agenda in mind that dictates the kinds of questions that
need to be asked; the structure or order can be abandoned to individualize the
interview according to a clients needs. Given the basic or introductory nature
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 QUESTIONS TO ENCOURAGE COMMUNICATION 129

of this book, systematic inquiry for the purpose of crisis assessment will not be
addressed further. The interested reader is referred to Brems (2000), which
deals with these issues in detail, providing outlines and guidelines. Intake in¬
quiry will be dealt with below as it is encountered by all novice clinicians. In
fact, this type of systematic inquiry is generally the first task of new clinicians
as they have their first contact with their first client.

General Guidelines About Questions

Clearly, regardless of type, questions are always somewhat directive. The cli¬
nician chooses what to ask and when, and through that action draws implications
about what is important. Even open-ended questions, which arise out of a cli¬
ent s agenda and verbalization, tell the client where the clinician places empha¬
sis and what draws the counselors curiosity. In that sense, no question is truly
unbiased. Given this reality, it is critically important that clinicians learn to min¬
imize the level of directiveness and implication in their questions. It would be
quite easy to use questions to influence clients unduly, to make hidden sugges¬
tions, to convey basic assumptions, or suggest predrawn conclusions.

Pitfalls in the Use of Questions

It is easiest to learn how to use questions correctly by discussing the pitfalls of
using (or phrasing) questions the wrong way. There are at least ten types of
questions that can be counter-therapeutic.

Suggestive Questions
One type of problematic question to avoid is the suggestive question. Sugges¬
tive questions give hidden (or not so hidden) advice disguised as a question.
Counselors using suggestive questions may not even be aware that they are giv¬
ing advice. They may need to listen with a third ear to how a question was
phrased to recognize that the client might receive it as advice. Suggestive ques¬
tions tend to start with stems such as “Don’t you think ... ?,” “Could you ... ?,”
“Couldn’t you .. . ?,” “Have you (ever) considered ... ?,” and similar suggestive
openers. Although the clinician may think that the question really just moti¬
vates the client to consider a point, the client is more likely to hear such a ques¬
tion as suggestive of the very action that follows the stem. Note the following
example:

CLIENT: Well, now you have the whole history of how my husband and I
end up in these screaming fits. I still don’t know how to get us to change
this dance we re doing. I can see it all developing afterwards. But while
130 CHAPTER FIVE

I’m in the middle of it I get so caught up in the emotions that it’s like I
can do nothing to change what I just know is gonna happen. ... Its not
like I haven’t tried, but. . . .

Pitfall: Use of Suggestive Question

CLINICIAN: Have you ever tried something like taking a deep breath to

slow yourself down while you are fighting?

CLIENT: I guess I could try that again, but I tried it once before and it

was a disaster. So I just don’t think that works.

Alternative: Use of Well-Phrased Open-Ended Question

clinician: What lands of things have you tried?
client: Oh, I’ve tried counting to ten—My mother always said that
works for her. I’ve tried just leaving the room, but he follows me and
then it just gets worse. A friend of mine said she just takes a deep breath
when she gets upset, so I tried that but that was a disaster. . . .
clinician: How was it a disaster? (The session continues productively
from there.)

This example shows that a suggestive question can be mistaken as advice

by the client even if it was not necessarily intended as such. It can also serve to
close the client down. If the suggestion is not well received by the client (for
example, is not perceived as a good suggestion), it can undermine the relation¬
ship between the client and counselor or may even decrease the therapist’s
trustworthiness and expertness in the client’s eye. An alternatively phrased
open-ended question makes the client do the work and suggests no particular
solution or course of action.

Assumptive Questions
A similarly problematic type of question is the inquiry that gives the client the
impression that the clinician expects a particular answer. Such assumptive
questions often start with stems such as “But you have . . . ?,” or “But you
haven’t... ?,” “You don’t really... ?,” or “Do you really... ?” Alternatively, they
end with a phrase such as “do you?” or “don’t you?”; “have you?” or “haven’t
you?” In other words, assumptive questions are not questions at all; they are
really statements disguised as questions. A convenient “do you?” (or similar
phrase) is tacked on to the end of a statement, turning it into a question in an
attempt to hide the assumption made by the clinician. Sometimes, assumptive
questions are even plain statements turned into a question merely through
voice inflection. For instance the counselor may highlight a word or phrase in
the middle of the statement and raise the voice questioningly at the end of the
sentence, as in “but you yourself have never done xyz?” Although occasionally
clients may miss the assumption, most commonly they hear it loud and clear.
 QUESTIONS TO ENCOURAGE COMMUNICATION 131

Clients then have to decide whether to comply with the assumption or to answer
honestly. The problem lor the therapist then becomes one of knowing whether
the answer the client gave was honest or given in a manner as to conform to the
expectation detected in the clinicians statement/question. The following ex¬
ample serves to demonstrate this issue.

CLIENT: He has been a druggie for years. Lets see . . . he’s twenty-three
now; he moved out when he was sixteen and a half. ... So yeah, he’s been
doing one drug or another for at least eight years. I can’t say that I like it
but I haven t exactly done anything about it, either. You know, in a way he
is just following in his mother’s footsteps. That was one of the reasons we
split up and I got custody.

Pitfall: Use of Assumptive Question

clinician: You yourself haven’t taken drugs now, have you?
CLIENT: Not really . . . (looks away)

Alternative: Use of Well-Phrased Question as Part of a Systematic

Intake Inquiry
CLINICIAN: I guess that brings me to one of my next questions. Have you
had personal experience with drugs?
CLIENT: Well, a little . . .
CLINICIAN: A little?

CLIENT: Yeah. I used to drink pretty heavily when . . . (Session continues

from here.)

This example serves to clarify that assumptive questions can lead clients
down a path of unintended dishonesty as they do not want to disappoint the
clinician. This is a particular danger during systematic inquiries when the cli¬
nician and client are still getting to know each other and when the counselor
wants to collect as much reliable information as possible. In the pitfall part of
the example, the client is at least giving clues that he may be less than honest
in response to the therapist’s poorly phrased questions. The use of “Not re¬
ally . . .” is often a giveaway that a client is skirting the truth. The fact that he
also looked away clearly suggests a rupture in the connection between clinician
and client. The counselor thus has an opportunity to repair the mistake by fol¬
lowing up on the original question with a better-phrased question that makes
no assumptions about the client’s personal drug use.

Pseudoquestions
Similar to assumptive questions, pseudoquestions are not questions at all. They
are actually disguised commands or directives. The pitfall in the use of these
132 CHAPTER FIVE

“questions” is that the client may feel manipulated by the pretense of a choice
when the reality is that the client is supposed to comply with a directive. It is per¬
fectly acceptable for a counselor to feel the need to direct a client. The problem
lies in pretending not to direct the client when this actually is the goal. If the
therapist, on the other hand, really has no preference and the question came out
inadvertently as a command, then perhaps more practice is needed at phrasing
questions open-endedly. The first set of examples that follows demonstrates a
mental-health-care provider’s use of a pseudoquestion, and how the directive
could have been phrased more appropriately. The second set of examples
rephrases a pseudoquestion into a genuine question to reflect that the clinician
actually does not have a preference and was not really giving a directive even
though the question sounded like one originally. The third and final set of ex¬
amples speculates as to what a client may think or feel (overtly or covertly)
when the counselor uses pseudoquestions.

Example Set One: Pseudoquestion to Directive

What the clinician said: What the clinician meant and could have said:

Do you want to get us started? Go ahead and start. OR Would you please get us
started now.

Would you like to start where we left off Let’s start where we left off last week.
last week?

Would you like to take a deep breath I’d like you to take a deep breath to calm down
to calm down? a bit.

Do you want to let me help you here? How about 1 help you with that?

Example Set Two: Pseudoquestion to Genuine Question

What the clinician said: What the clinician meant and could have said:

Do you want to get us started? Do you want to get us started or do you want
me to?

Would you like to start where we left What do you think about starting where we left off
off last week? last week? Or is there anything else that you
would like to talk about first?

Would you like to take a deep breath You seem very shaken by this. Would you like
to calm down? some help calming down before we go on or are
you okay as is?

Do you want to let me help you here? Would you tell me if you want or need any help
with anything?
 QUESTIONS TO ENCOURAGE COMMUNICATION 133

Example Set Three: Pseudoquestion and Client Reaction

What the clinician said: What the client may feel or think but says or does:

Do you want to get us started? Thinks: No! Why do you always pretend like 1 have a
choice.
Says: 1 guess so. . ..
Would you like to start where we Thinks: As if 1 have a choice?
left off last week? Says: Okay . . .
Would you like to take a deep breath Feels: HELP!
to calm down? Says: Yes.
Do you want to let me help you here? Thinks: Oh, 1 guess I’m too stupid to do it alone!
Says: That’s okay. ... 1 can do it, can’t 1?

These examples show that pseudoquestions are not a pitfall because they
are commands in disguise. They are pitfalls because they pretend to give a
choice when they do not. In some instances in therapeutic work, being direc¬
tive is important. In the examples, the third occasion in each set is best ap¬
proached as a directive. The client clearly needs assistance with calming down
and a question, whether pseudo or open, is not the best approach. Thus, the
important lesson from the pseudoquestions is that if a directive is needed,
phrase it as such. If options truly exist, they need to be verbalized. That way the
client is not left guessing as to the true meaning or intent of the counselor’s
question or statement.

Judgmental Questions
Judgmental questions are the reason why questions starting with “why” have
fallen into disregard among counselors and therapists. Most judgmental ques¬
tions begin with “why,” and a generalization has occurred that since these are
judgmental questions, all “why” questions are judgmental. This is simply not
true. Occasional well-phrased and intentioned “why” questions can be quite
appropriate, as will be demonstrated below. However, “why” questions that
suggest judgment are truly pitfalls in questioning. Such questions put the cli¬
ent on the defensive or create some sense of discomfort in the client. For what¬
ever reason, the clinician phrased a question in a way that sounded judgmen¬
tal to the client. While some questions will sound judgmental to almost anyone,
there are some questions that may be perceived as judgmental by some, but not
other, clients. It takes some empathy for and knowledge about each and every
client to be able to anticipate whether a certain question will result in defen¬
siveness or discomfort in the client. One prime example of a question that will
sound judgmental to almost anyone is the still-often-used ‘“Why did you do
that?” It is best to eliminate this question from a counselors vocabulary as most
clients will react defensively. There are many better ways to arrive at the same
134 CHAPTER FIVE

point. For example, “How did you decide what to do at that point? will give
the therapist the same information without inducing defensiveness in the cli¬
ent. The following example points to some of the pitfalls of and alternatives to
judgmental questions.

CLIENT: Well, my father and I were at it again this week. It doesn t mat¬
ter that I am hundreds of miles away—we talk on the phone and there
we go. He was being a total jerk again, giving me the usual lecture about
responsibility and respect and blah blah blah. ... I really let him have it
this time. And I have no regrets—well, I feel a little bad for calling him
a shithead . . . and I hung up on him on that note. . . . Yikes.

Pitfall: Use of Judgmental Question

clinician: Couldn’t you have dealt with that a little differently this

time?
client: (defensively) I don’t think so! You should have been there and
you would understand! He can be a real jerk. . . .

Alternative: Use of Well-Phrased Open-Ended Question

clinician: Now that you’re looking back at it, it almost sounds like there
may be some things you wish or that you could have done differently?
(picking up on the client’s “yikes" as regret)
client: Oh, yeah! (sounds relieved at being understood) I have gone
through the scenario in lots of different ways since then. I know I tend to
overreact. I get so caught up in the moment that I forget that he’s only
human too. (smiles)
clinician: What are the different ways you have envisioned? (Session

continues from the re.)

This example demonstrates how doing something that leads clients to be¬
come defensive impedes therapeutic work. Clients often come to therapy be¬
cause they already feel judged by others and judge themselves. What they need
from their counselor is unconditional positive regard (yes, Rogers was right!),
as well as understanding (Kohut convincingly points this out). When they per¬
ceive judgment (that is, lack of understanding and acceptance) from the ther¬
apist, clients feel the need to protect themselves, and the only way they likely
know how to do this is to become defensive. Defensiveness translates into less-
than-genuine disclosure and gets in the way of therapeutic progress. This ex¬
ample also clarifies that the difference in phrasing can be very subtle. The
smallest nuance in how a question is worded can make the difference between
judgment and genuine exploration.

Attacking Questions
Attacking questions are closely related to judgmental questions. Fortunately,
they are more obvious and hence more easily avoided. This type of inquiry is per-
 QUESTIONS TO ENCOURAGE COMMUNICATION 135

ceived by the client as demeaning or embarrassing. Regardless of the clinician’s

original intent this type of question serves to shame the client or demonstrates
the clinicians power over the client. Attacking questions must be eradicated
from a clinicians repertoire of questions. They are harmful and counterproduc¬
tive to therapeutic work. Developing good self-awareness is the prerequisite for
not using attacking questions. Only a counselor or therapist who does not need
to feel one-up vis-a-vis a client will be able to avoid attacking questions. Clients
make themselves very vulnerable in clinical situations; attacking questions take
advantage, however subtle, of this vulnerability by knocking the client down
even further. Examples of attacking questions include “Why are you telling me
this?”; “What’s the point of that story?”; “Aren’t you listening to me?”; “Is that
supposed to make sense?”; “So?”; “So what?”; “Don’t you get it?”; “Can’t you
understand that simple idea?”; and many others. The following example dem¬
onstrates die negative power of attacking questions that were phrased rather
subtly.

CLIENT: My best friend Jim had a big fight with his wife this week. He
was really upset—came over at midnight and rang my doorbell. He’s
never done anything like that before. I was pretty freaked out. I guess he
just really needed to talk to someone and had stormed out of his house so
he couldn’t call. . . . What a night we had. My goodness, the poor guy.
They have been struggling for a while, only I didn’t know it because he
never said anything about it. . . . (hesitates)

Pitfall: Use of Attacking Question

CLINICIAN: So what is your point here?
CLIENT: (taken aback; hesitates with answer) Um, I don’t know. . . .
(blushes; shuts down)

Alternative: Use of Well-Phrased Open-Ended Question

CLINICIAN: What a powerful experience. What do you make of it? (em¬
pathizes first with the client’s emotional state, then inquires as to what the
client is driving at)
CLIENT: Well, I am shocked he didn’t tell me before. We are best friends!
CLINICIAN: You’re surprised . . . (client interrupts this unnecessary
paraphrase)
CLIENT: Yes. We have known each other for twelve years! We’ve been

through a lot together. (Session continues from here.)

This example shows that attacks lead nowhere. There is really no excuse for
using such an intervention. It tends to be driven by therapist insecurity, impa¬
tience, and other less-than-therapeutic traits that need to be self-monitored.
The alternative shows that with a little empathy a well-phrased open-ended
question will open doors and keep disclosure going.
136 CHAPTER FIVE

Controlling or Intrusive Questions

This type of question is intrusive in that it ignores the client s agenda and needs,
and focuses instead on the desires and wishes of the therapist. There are, of
course, times in treatment when a counselor appropriately changes agenda or
direction of a session. Such a change is predicated on a genuine need to switch
gears for the sake of the client. This may happen, for example, with a client who
does not stay on a productive or helpful course. In that situation it is the coun¬
selor’s responsibility to bring the duo back to a useful topic area. When the
therapist switches focus, though, not because it is therapeutic, but for some
personal reason, the choice becomes controlling and, at times, intiusive. The
counselor may be uncomfortable with the conversation (for example, the client
is talking about sex, or values the clinician does not agree with). Sometimes
quite the opposite is true, with a clinician who seeks such specific detail that
focus essentially shifts away from die client and to a preoccupation of the thera¬
pist that may even be voyeuristic (for example, the clinician may ask overly
personal and intrusive questions about a client’s sexual practices). The pitfall of
controlling or intrusive questions is the change of focus from client to clinician,
usually for some personal reason of the clinician. Such reasons can clearly be
multifold and, if they interfere regularly, suggest that the clinician may not be
sufficiently emotionally healthy to be in a counseling or therapeutic role. A list¬
ing of some possible reasons for controlling or intrusive questions follows.

Examples of Clinicians’ Reasons for Controlling

or Intrusive Questions
• idiosyncratic topical preoccupation by the clinician (for example, always
shifting conversation to marital issues or financial matters)
• voyeuristic preoccupation with a topic by the clinician (for example,
overly personal questions about sexual practices)
• theoretical preoccupations by the clinician (for example, leading question¬
ing regarding how a client’s parents may be at fault for current problems)
• preoccupation with concerns related to the clinician’s practice specialty
(for example, a traumatic-stress therapist always and only focuses on that
aspect of a client’s case)
• avoidance of certain topics by the clinician because they are deemed
unimportant or irrelevant (for example, steering clients away from talking
about medical or nutritional issues)
• avoidance due to embarrassment about certain topics in the clinician (for
example, clinician who cannot talk about sex)
• avoidance due to countertransference about certain topics in the clinician
(for example, the clinician’s personal conflict with authority figures)
. redirection of the client because of disagreement (for example, clinician
refuses to talk about abortion as a possibility with a newly pregnant client)
 QUESTIONS TO ENCOURAGE COMMUNICATION 137

. • redirection of a client because of fear of a topic (for example, clinician

who is unable to follow up on suicidal or violent threats because of fear of
what the client may say or do)

Clearly, these examples of reasons demonstrate that control and intrusion

arise out of unresolved personal or professional issues of the care provider. The
client is pushed to an agenda or to a level of depth of exploration that is un¬
desirable for that individual, but desirable for the clinician. Not surprisingly,
controlling or intrusive questions that occur with regularity tend to be indica¬
tors of countertransference. The client will feel unheard, misunderstood, and
uncared-for at best; invaded and possibly traumatized at worst.

Tangential Questions
On the surface, tangential questions may look similar to controlling or intrusive
questions, in that they, too, shift focus. However, where controlling or intrusive
questions arise out of a clinicians need to be preoccupied with or to avoid cer¬
tain topics, tangential questions usually stem from a lack of empathic attune-
ment with the client. These questions are off the mark because of some lack in
understanding of the client. Of course, it is possible that lack of empathic at-
tunement and understanding have arisen due to some of the reasons provided
under controlling or intrusive questions; however, most of the time this is not
the case. If it is the case, what appears tangential will often become more ob¬
viously controlling or intrusive as it repeats itself. Tangential questions fail to get
at the heart of the client’s matter and usually hone in on a nonessential detail
in the clients communication. They are not totally out of context or off topic;
they are slightly off, not catching the essential message that the client is at¬
tempting to explore or communicate. Tangential questions suggest that the cli¬
nician needs to enhance empathic skills. If frequent, such questions tend to
keep therapy or counseling somewhat aimless and superficial. An occasional
tangential question rarely does any harm, especially if the therapist recognizes
the misattunement and corrects it (unlike attacking questions, which can de¬
stroy a therapeutic relationship in a single application). The following example
demonstrates a tangential question along with a nice recovery and reattune-
ment on the part of the clinician.

client: Being diagnosed with multiple sclerosis has turned my life up¬
side down. It has just about changed everything—my career path, the
way I view my children and my husband, even the way I approach each
day. It’s all so different now. You know, I thought I was invincible, and
when I was feeling tired and draggy before or if my muscles didn’t quite
cooperate, I dismissed it. Now it has meaning—horrible meaning. My
god (begins to weep)—then I ask, why me?? You know, I’ve always taken
care of myself, I eat well and exercise. I worked hard all my life. I was
there for my children. It’s all different now.
138 CHAPTER FIVE

CLINICIAN: Your life seems completely changed. . . . (a paraphrase to let

the client know the clinician is listening and present)
CLIENT: Yes . . . (nodding; slowly recovering her emotions) . . . Nothing
is the same. I don’t know what to do and where to start. Do I focus on my
treatment or on my responsibilities, do I quit my job, do I hire a house¬
keeper, do I just wait and see how things are going to unfold, should I tell
my childrens teachers? Should I tell my friends and how about acquain¬
tances, do they need to know? Should I see another physician, you know,
get a second opinion about all this?
CLINICIAN: Do you want to tell other people about having been diag¬
nosed? (tangential in that this is not the essence of what the client is con¬
cerned with)
CLIENT: I don’t know. (exasperated) Don’t you see, I don’t know. ... I
don’t care who knows! I’m just so worried. . . .
CLINICIAN: So is it your job you are worried about? (tangentially honing
in on yet another nonessential detail)
CLIENT: No. Yes. Well, partly, but that’s really not it—it’s more the
whole thing, you know?
clinician: You need to figure out all the implications, sort of one by
one and then for each one figure out what you need to do. Is that it?
(starting to catch on to the whole picture now)
CLIENT: Yes. You don’t really notice how complex your life is until some¬
thing like this happens and then you realize lots of people depend on you
and that you yourself depend on your body being there for you.
clinician: What has shaken you the most? (finally a good open-ended
question that captures the client’s emotional state and need)
CLIENT: The fact that the very foundation my life rests on is slowly
breaking apart. . . .
clinician: Your body is letting you down?! (a nice paraphrase, almost a
reflection [see Chapter Six])
CLIENT: Oh yes. That’s it. How can I trust anything now? (Session goes
on from here.)

This example demonstrates that asking focused and relevant open-ended

questions is predicated on understanding the essential aspect of a client’s com¬
munication. It is very easy to pick up on a detail and ask a specific question
about it. It is much more difficult to recognize what the essential question is that
the client is asking herself and to help her verbalize that question so that prob¬
lem solving may begin. The example also shows how sensitive and non defensive
listening to the client after a question can help the clinician recognize when a
question was tangential and when a different approach is called for. In the ex¬
ample, it took a few attempts before the clinician recognized the tangentiality
of her questions; once recognized, she was able to change tack and reattune to
 QUESTIONS TO ENCOURAGE COMMUNICATION 139

the client. The client acknowledged diis reattunement through her heightened
responsiveness.

Content-Diverse Multiple Questions

This pitfall occurs when a mental-health-care provider asks several questions all
at once and each of the questions addresses a slightly different issue or content.
Sometimes, counselors will phrase the same question in two or three different
ways and thus will ask multiple questions. That is not what is referred to here, as
in essence only one question was asked. When multiple questions get at diverse
contents, the client may be left with confusion as to which question to answer.
Multiple questions of that type indicate confusion and lack of organization on the
clinicians part. Clearly, the therapist does not have the direction of the question
well enough formulated to stick with it; one question followed by another one of
a different content suggests uncertainty about which way to take the session. It
is no wonder that client and clinician sometimes end up feeling confused and
floundering with this style of inquiry. In other instances, however, multiple ques¬
tions do not appear to bother clients much at all. They may merely choose the
question they deem most relevant or important and answer it, ignoring the rest.
The clinician then only has to decide whether it is important at some point to fol¬
low up on the other questions. Following is an example of multiple questions.
The first section (pitfall) reflects inappropriate content-diverse multiple ques¬
tions; the alternative demonstrates multiple questions that are not problematic
(though perhaps still not ideal since such multiple questioning is not efficient).

CLIENT: My sister and I are in total agreement that the family reunion
was once again the typical disaster that it always is. Why do we keep
going? It sucks every time but somehow both of us keep hoping against
hope that something will change and we miraculously will be a happy
healthy family. Fat chance, right? My brother was drunk again, of course.
You know, the difference was that this time he arrived drunk. I really got
on his case about it too because he brought his little girl and if he wants
to drive himself around drunk that’s one thing. But to drive his kid around
like that, now that’s child abuse. So I told him I’d report him to the author¬
ities. You should have seen my mother jump on that one. You’d think she’d
agree with me on that but NO—she was on his side. What is her problem
anyway? Maybe she’s covering for my father. He is a drunk too. I bet he
used to drive us around drunk too. We were just too little to notice. . . .
Thank goodness he wasn’t there this time. Though nobody knows why.
He could be dead for all we know. . . .

Pitfall: Content-Diverse Multiple Questions

CLINICIAN: So your father drank too? So your mother sided with
your brother? Did you end up reporting him? (inappropriate multiple
questions)
140 CHAPTER FIVE

CLIENT: Yeah, I reported him. Turns out they already had a file on him.
A neighbor had turned him in. They didn’t do anything though. Said he d
never really hurt his kids. . . .
CLINICIAN: Is there anything else you want to do about that situation?

(good open-ended question)

CLIENT: No. I feel like I did what I could. I know he wouldn’t let me take
the kid. I’ve offered before but in some warped way he really loves her. ...
clinician: What was it you offered before? (Session continues
from here.)

Alternative: Content-Repetitive (Appropriate) Multiple Questions

clinician: Sounds like a lot happened! What has stayed with you the
most? You know, what affected you the most?
CLIENT: I guess the thing with my brother and his daughter. I really do
worry about her. When I called the child protection guys they said . . .
(Session continues from here.)

This example demonstrates an instance of multiple questioning that did not

appear to bother the client. The client chose to address the question closest to
her heart and went on from there without concern about the other questions.
For the time being, the therapist followed her lead and dropped pursuit of the
other questions. As often occurs in content-diverse multiple questioning, some
of the questions were more relevant than others; some were almost tangential
in nature. They are often not good open-ended questions as they tend to be fo¬
cused on specific detail. The alternative in the example demonstrates a much
superior approach to an open-ended way of questioning along with a multiple-
question format. The two questions got at the same issue. This way of phrasing
can have advantages and disadvantages. It is less efficient, but sometimes
serves to clarify further what it is the clinician is asking.

Closed Questions
The discussion of multiple questions alluded to the fact that there are certain
traits or characteristics of good open-ended questions. This issue will be dis¬
cussed in detail below. However, another excellent means of deciding whether
a question was well-phrased is the differentiation between open-ended and
closed questions. Closed questions allow clients to answer with a simple phrase
or even to give a yes-no answer. They make it easy for clients to evade issues and
do not encourage self-disclosure effectively. The pitfalls are at least threefold.
First, clients do not have to provide a lot of information, and the ensuing inter¬
action between therapist and client may not be very rich. Second, counselors
who use closed questions end up doing all of the therapeutic work for the client,
who merely has to sit and answer yes or no. Finally, closed questions require a
lot of verbalization on the part of the clinician, a practice that is not conducive to
an active and collaborative way of communicating. This issue is related to shot-
 QUESTIONS TO ENCOURAGE COMMUNICATION 141

gunning, the next pitfall to be discussed. Examples of closed questions and

open-ended alternatives are provided below.
One other important point needs to be made before delving into examples.
Not all uses of closed questions are inappropriate. In fact, when used wisely
and purposefully, closed questions can be useful tools in the hands of a skilled
clinician. Wise uses of closed questions occur to focus clients during crises, shut
or slow down overly talkative clients, pace and organize the thinking and talk¬
ing of clients whose thoughts are racing, diffuse a client s anxiety by giving them
a clear and simple focus, get clear information about a specific issue, or direct
a client toward an important point. These purposes are well served with closed
questions that force a client to keep answers brief and hone in on the essential
issue queried by the clinician. Once the goal has been met and the task accom¬
plished, the clinician will once again switch to open-ended questions. Positive
uses of closed questions are outlined in Table 5-2.

Closed Questions Open-Ended Alternative

Do you like your mother/father/etc.? How do you feel about your mother/father/etc.?

Did you grow up here? Where did you grow up?

Did you like school? What were your years like in high school?

Do you have a best friend? What can you tell me about your best friend?

Do you like to read? What are some of your hobbies and what do you
enjoy about them?

Is your apartment new? Tell me about the place where you live.

Do you like the weather here? How do you adjust to and cope with the different
seasons here?

Were you hospitalized after the accident? How bad were your injuries?

Did you ask him xyz? What did you say after that?

Do you know how to ski? What do you do for enjoyment in the winter?

These examples highlight how easy it is for a client to respond with a simple
yes or no to closed questions. It is much more difficult to answer with a simple
phrase when a good open-ended question is asked. More hints on how to con¬
struct good open-ended questions are provided in a later section of this chap¬
ter. For now, the examples should serve to demonstrate that closed questions,
when not used for a specific reason (as outlined in Table 5-2), are not conducive
to facilitating self-disclosure or interactive and collaborative exchanges be¬
tween client and clinician.

Shotgunning
This final pitfall is related to the use of closed questions. In fact, it will only oc¬
cur if a clinician overly relies on closed questions. Shotgunning is defined as a
series (a long series) of closed questions that cover nothing in depth and much
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 QUESTIONS TO ENCOURAGE COMMUNICATION 143

in breadth, that is, superficially. The client who is the target of this series of ques¬
tions is likely to feel bombarded, if not assaulted, by a curious and noncaring
therapist who asks endless questions without really allowing the client to self-
disclose. Since answers to closed questions are by definition very brief or mere
yes-or-no answers, clients end up talking much less than the shotgunning clini¬
cian, who reels off one question after another. This clinician will cover a lot of
ground, but when looking back at the information, the counselor will notice that
there is a dearth of meaning and that the essence or emotional aspects of the
client remain hidden. A brief clinician-client interaction based on shotgunning
follows.

CLINICIAN: Did you grow up here?

CLIENT: Yes, I grew up in Anchorage.
CLINICIAN: Did you go to school in Anchorage?
CLIENT: Yes.
CLINICIAN: Did you graduate from high school?
CLIENT: Yes.
CLINICIAN: Which one?
client: East High.
CLINICIAN: When?
CLIENT: 1995.
CLINICIAN: Did you go to the University of Alaska Anchorage after
graduation?
CLIENT: Yes.
CLINICIAN: Did you graduate?
CLIENT: No.
CLINICIAN: Did you drop out?
CLIENT: No.
CLINICIAN: What happened? (the first open-ended question)

CLIENT: I was kicked out.

CLINICIAN: Did you get a job after that? (really missing the opportunity
for open-ended follow-up here)
CLIENT: Yes.
clinician: Where?
client: At Wal-Mart.
CLINICIAN: Do you still work there?
CLIENT: Yes.
CLINICIAN: So you have worked there how long?
CLIENT: Three years.
clinician: Do you like your job?
CLIENT: No—it sucks.
clinician: Are you looking for a different job?
CLIENT: No.
144 CHAPTER FIVE

clinician: Why not? (addingjudgmentalism to shotgunning)

CLIENT: I don’t know (at this point does not trust the clinician)

This session could literally go on like that for hours, unless the client got so
fed up as to get up and leave—-a possibility to be recommended given the skill
level of this therapist. This transcript hopefully serves to demonstrate how little
real information is obtained through shotgunning. This counselor asked ques¬
tions about several areas of the client s life, as one would during an intake (that
is, a systematic inquiry), but has very little to show for the many questions. The
content stays on the surface, is unelaborated, and discloses nothing essential or
meaningful about the client. The client no doubt walks away feeling insulted or
assaulted and is not likely to feel heard, cared for, or understood.

Additional Thoughts About the Use of Questions

Once aware of the potential pitfalls in the use of questions, the clinician is ready
to tackle some of the specifics about how to phrase questions with success. The
pointers given here apply to all three types of questions, that is, to open-ended
questions, systematic inquiry, and clarifying questions. When humans learn to
speak, they also learn to ask. The way they learn to make questions is via a few
very specific words that give questions a certain direction. These words of course
are what, how, why, when, who, and where. These question stems are useful in
therapy as well and will solicit specific information from clients as shown in
Table 5-3.
Clearly, in phrasing questions all of these words—what, how, why, when,
who, and where—will come in handy to direct a client down a particular path
of inquiry. Questions that begin with question words are usually more specific
than questions not opened with these words. It is important for clinicians to re¬
member that “why” questions in particular can lead to defensiveness in the cli¬
ent. It is preferable to rephrase a “why” question. There maybe times, however,
when this is not possible, and then a cautious “why” question may be appro¬
priate. Finally, counselors do not HAVE to ask questions. Much can be accom¬
plished with simple statements. Further, embedding questions in statements
that reflect empathy, understanding, caring, and listening is extremely helpful
to rapport. Especially in systematic inquiry, when many questions need to be
asked, it can be helpful to phrase as many questions as possible in the form of
statements instead and to embed as many questions as possible in restate¬
ments, paraphrases, and reflections (to be discussed in the next chapter).

Open-Ended Questions

Everything leading up to this point has hinted at the great importance of open-
ended questions in therapy and counseling. Given their importance, it is critical
 QUESTIONS TO ENCOURAGE COMMUNICATION 145

Purposes of the “Question Words”

Word Question Example Purpose

What? What happened next? Elicits facts and specific details about a situation
How? How did that come about? Elicits process or sequence about a situation;
How did you feel at that point? may be used to elicit emotions
Why? Why do you suppose she Elicits reasons; may lead to intellectualization,
chose to do that? rationalization, or defensiveness
When? When did it happen? Elicits specific detail about various time frames
Where? Where did you go from there? Elicits specific detail about location(s)
Who? Who all was part of that? Elicits specific detail about involved players

that counselors and therapists learn to phrase good open-ended questions and
that they understand their applications and purposes. To recapitulate, the pri¬
mary purposes of open-ended questions are encouragement of self-disclosure
and facilitation of collaborative interaction (or communication). How ques¬
tions are phrased can greatly contribute to or detract from these purposes. Ob¬
viously, the pitfalls outlined above need to be avoided. However, there are also
a few simple hints about how to phrase good open-ended questions that should
help clinicians in training learn how to use this essential skill in their counsel¬
ing or therapy practice.
It may go without saying that first of all a clinician must have a reason for
asking a question. In other words, questions need to be intentional and purpose¬
ful. Questions are not asked to kill time or end silences. Once the clinician has
decided to ask a question (that is, has identified a need and purpose for a ques¬
tion), timing of the delivery of that question is carefully considered. Clients are
best not interrupted while still speaking, just to ask a question. It is not good
practice to disrupt a client s concentration in that manner. It is generally more
helpful to wait for questioning until an actual break takes place in the client’s ver¬
balization. On the other hand, if a clinician has a burning question, it is not a
good idea to wait too long to ask it. Waiting too long may result in the client hav¬
ing moved on to another topic, making the question poorly timed or irrelevant.
It is important to be sensitive to the individual needs of each client with re¬
gard to the number and speed with which to deliver questions. What may feel
like bombardment to one client, may be quite comfortable for another and vice
versa. Thus, the number and nature of questions to ask are best adapted spe¬
cifically to each clients idiosyncratic needs, traits, and characteristics. Knowing
a client well enough to make this type of judgment may take some time and
may be based in some trial-and-error learning.
It is also important to ask enough questions, that is, a sufficient number of
questions to achieve the desired focus and clarity. Not asking too many questions
146 CHAPTER FIVE

refers to the reality that clients may feel overwhelmed when clinicians ask for
too much information all at once. Knowing when to ask follow-up questions
and when to let go of an issue or topic is critically important. Clients must never
feel harassed by excessive questioning; on the other hand clients should not be
allowed to retreat from providing information that is needed for proper treat¬
ment planning and diagnosis. If follow-up appears necessary for the sake of ap¬
propriate treatment decisions or better understanding of the client, the coun¬
selor should ask the question. If, on the other hand, follow-up would add little
additional or crucial information and may be perceived by the client as intru¬
sive, the therapist may choose to forego the questioning.
Questions are best phrased in such a manner that they are perceived by the
client as supportive and therapeutic, not judgmental or presumptuous. This is¬
sue clearly relates to the many pitfalls outlined above. It deserves rementioning
if merely to point out that questions often can be asked in a manner that feels
supportive to the client rather than challenging or cold (unfeeling). It is often
helpful to introduce difficult questions with a gentle lead-in or preface that ex¬
presses caring and purpose. An example of such a lead-in may be “I realize this
is a difficult issue. However, I feel it’s important for me to ask if....” Another pos¬
sible lead-in may be something like “I have a difficult question for you that you
may choose not to answer if it’s too painful for you....” Embedding open-ended
questions in such a context of understanding and empathy helps clients answer
even the most difficult questions. If clients feel understood and cared for they
will be much more likely to be willing to disclose very intimate details of their
lives than when they feel intruded upon. Relatedly, it is generally best to let
open-ended questions arise from the client’s choice of agenda and need and not
from the therapist’s needs. In other words, the area for questioning using open-
ended questions is generally chosen by the client, not clinician (very unlike sys¬
tematic inquiry, where the area of questioning is determined by the therapist).
Once questions have been asked of a client, the individual needs to be given
enough time to respond to them. This may seem to be an obvious point, but it
is a necessary caution, especially since individual needs for pauses after a ques¬
tion has been asked and before the answer is given are greatly diverse. Clini¬
cians adapt the length of the pause between question and answer to the idiosyn¬
cratic needs of the client, a time period that is related to cultural practices and
expectations. For reasons of time efficiency and the avoidance of shotgunning,
it is good practice for clinicians to reconsider asking any open-ended question
to which they already know the answer. Occasionally, in asking clarifying ques¬
tions that are open-ended in nature, this rule will be broken for a therapeutic
reason or purpose. This specific use of questions to which the clinician already
knows the answer will be expanded upon in the chapter that deals with clarify¬
ing questions in the context of creating cognitive insight.
Finally, it is often, but not always, helpful first to communicate understand¬
ing of what the client has just communicated in the form of a paraphrase, re-
 QUESTIONS TO ENCOURAGE COMMUNICATION 147

flection, or restatement before asking an open-ended question. This will let the
client know that the clinician has heard and understood what the client has dis¬
closed already. Embedded in such a context of caring, clients feel comfortable
continuing to disclose and that a truly collaborative effort is made on behalf of
their growth or problem solving. In closing this section it is important to reiterate
an important point: All open-ended questions need to be phrased in such a man¬
ner that the client has many options in how to answer them. Any question that
can be responded to with a simple yes or no or a very brief phrase probably does
not meet the criteria for an open-ended question. Instead, such a question is
likely to have been closed, and if overused may discourage spontaneous self¬
disclosure.
If clinicians follow these few simple rules about open-ended questions, they
should be quite successful in soliciting specific information from their clients
and in facilitating self-disclosure. Often a few open-ended questions early in a
contact with client will give the client the clear message that the clinician is will¬
ing to listen and interested in receiving as much information about the client
as possible. This will then motivate the client to self-disclose increasingly spon¬
taneously and will actually reduce the need for questions later in the therapy or
counseling process. Although several examples of open-ended questions were
provided in the “Pitfalls” section above, a brief sample transcript of an exchange
follows that highlights the successful use of open-ended questions.

Sample Transcript of Open-Ended Questions

CLINICIAN: How have you been feeling this week? (opening session with
an open-ended question)
CLIENT: That is such a hard question, even though you ask it every

week. . . .
clinician: What makes it hard? (following up with yet another open-
ended question)
CLIENT: Oh, I’m not sure. Probably the fact that I really don’t always pay
attention to my feelings. But then that’s why you ask, isn’t it?
CLINICIAN: (merely smiles and nods)
CLIENT: Well, how have I been feeling. I guess it’s been an okay week—
feelings-wise. (smiles) Seriously, though, I have felt pretty good. I had no
moments of real crisis. . . .
CLINICIAN: How are you feeling right now? (another open-ended

question)
CLIENT: Oh, nervous, I suppose. Just kind of anxious about not being
able to give you a better answer. . . .
CLINICIAN: What does anxious mean to you? (another open-ended

question)
CLIENT: Well, it means . . . (Session continues from here.)
148 CHAPTER FIVE

Skill Development Recommendations

Recommendation 5-1 Turn the following closed questions into open-

ended ones:

• Did you graduate from high school?

• Do you like hiking?
• Do you notice a difference?
• Do you have any friends in this town?
• Do you want to change your mood?
• Do you know how to make a nutritious meal?
• Do you get along with your mother?
• Do you have a car?
• Do you have an intimate relationship?
• Do you want to make a change?

Answer each question as it was originally written and as you rewrote it.
What do you notice? How does the rephrasing improve each question?

Recommendation 5-2 Identify the pitfalls in the following questions. Then

rephrase each question to turn it into a therapeutic question.

• You didn’t think that was the best approach, did you?
• How did you figure this could possibly work?
• Why didn’t you ask her to come with you?
• Where are you going with this story?
• Did you never even consider her feelings?
• Did you figure out that this was a poor way to do this?
• Was that the right thing to do?
• Why did you do that?
• How can you possibly justify this action?
• You didn’t divorce him, did you?
• Do you like your father?.
• You are taking drugs?
• Do you really think this will work?
• Do you want to end the session now?
• Couldn’t you have said that differently?
• Why would you try that?
• Did you hear a word I said?
• Would you give me the nitty-gritty details of that sexual encounter?
• Did you like the job? And who got you into physics anyway? Hoiv old
were you when you graduated?
 QUESTIONS TO ENCOURAGE COMMUNICATION 149

Look at each question as it was written originally and put yourself in the
clients place. How would you feel about each question? Then look at how you
have rewritten each question. Does your reaction change? How? To what do
you attribute the difference in your reactions to the questions?

Recommendation 5-3 From now on, as you interact with family members
or friends, experiment with open-ended questions, avoiding the pitfalls dis¬
cussed above. What are the differences you notice in how people respond to
you ? What are you noticing in terms of changes in your relationships with
others as you use this form of interaction?

Systematic Inquiry

The primary purpose of systematic inquiry is to collect a specific body of data

about a client. For the novice clinician, the systematic inquiry of greatest con¬
cern is that engaged in during an intake interview. During this initial session
with a client, die counselor needs to collect sufficient data to gain a thorough
understanding of the client that can be used to arrive at a diagnosis and a treat¬
ment plan. Although it is beyond the scope of this book to deal with the intri¬
cacies of intake interviewing as a whole, the systematic-inquiry process is out¬
lined briefly. Readers who are interested in learning more about the intake and
early-assessment process with a new client are referred to Brems (1999), which
oudines this early collaboration with clients in detail.
Systematic inquiry in an intake interview centers around data collection in
a number of areas in a client’s life. The interview usually begins with an explo¬
ration of the presenting concern and from there moves to taking a client s his¬
tory. Included in the client history are the following topic areas: family history,
sexual history, social history, academic and professional history, developmental
and health history, substance use history, and nutritional and exercise history.
Further, the counselor notes behavioral observations about the client and pays
attention to the persons strengths. Within each of these categories very specific
information is sought. Regardless of the importance of this information, how¬
ever, when the counselor recognizes that the client is becoming overwhelmed
by the intense questioning, inquiry is interrupted for the sake of rapport. Clini¬
cians use their clinical judgment about when to abandon systematic inquiry dur¬
ing an intake to maintain a good relationship with the client. For example, if very
painful contents are discussed, it may be important to slow down and make
sure that the client is not overwhelmed with affect or racing thoughts. An em-
pathic listening and questioning style is essential. Of course, it would be asking
the impossible of the counselor to develop all components of therapeutic rap¬
port in a single session. A therapeutic relationship develops over a long period
150 CHAPTER FIVE

of time; however, often the foundation is laid in the very first hour of client con¬
tact, while the client’s feelings of vulnerability are heightened by the newness
of the situation. Nevertheless, the initial session is very structured because the
counselor has a clear agenda, namely the systematic inquiry into the client’s his¬
tory and presenting concern. Directiveness and clarity about the focus of the
questions is essential and conducive to the purpose of this process.
The content sought in the systematic-inquiry portion of the intake is sum¬
marized in Table 5-4. The transcript that follows, a selected portion of an in¬
take interview, demonstrates how a systematic inquiry is accomplished, with its
juggling act between data collection and rapport. It points to the importance of
embedding systematic-inquiry questions in a context of caring, empathy, and
understanding. As is true for open-ended questions, systematic inquiry will be
most successful if the questions are prefaced with appropriate restatements,
paraphrases, and reflections that let the client feel understood, heard, and lis¬
tened to. All of the various questioning pitfalls, especially shotgunning, need to
be avoided.

Sample Transcript of a Systematic Inquiry

clinician: Let me shift gears a little bit now. To understand all the
circumstance of your depression, I’d like to ask you some questions now
about your health and related issues. Sometimes physical things are
tied to depressive feelings, and I want to make sure that I am not mis¬
understanding what is going on with you. Alright?
CLIENT: Sure, I kind of figured as much. . . .
clinician: Alright then. Let me start by asking about your diet. What’s
a typical day like for you as far as food intake is concerned?
client: Well, most of time I eat breakfast, but not every day. I’m usually
too busy to eat lunch but I generally make a point of eating a solid dinner
every day.
clinician: Do you snack in between?

CLIENT: Yeah, usually. But I try to eat healthy snacks.

clinician: That’s terrific. What kind of snacks?
CLIENT: Oh, like popcorn or crackers or stuff like that. Sometimes a
piece of fruit. . .
clinician: How many snacks do you eat in a day?
CLIENT: Oh, just one.

CLINICIAN: When do you usually eat that snack?

client: Usually in the afternoon, since I skip lunch. A lot of times I get
hungry around two o’clock or so. That’s when I eat my snacks.
CLINICIAN: So tell me, what kind of snack did you have yesterday?
client: I had a bag of popcorn.
 Topics for Systematic Inquiry in an Intake Interview

Inquiry Area Questions to Be Answered

Presenting Concern • What is the overriding presenting concern?

• What are the circumstances?
• When does the problem arise?
• Where does the problem arise?
• How does the problem arise?
• With whom does the problem arise?
• How often does the problem arise?
• How intense is the problem?
• What is the history of the presenting concern?
• How long has the problem been occurring?
• How has the problem changed over time?
• When is the first time the problem was noticed?
• When is the last time the problem was not at all present?
Family History— • Identification of all family members with whom client interacted
in Family of Origin childhood
• Family interactions during childhood and adolescent years
interactions with siblings, stepsiblings, half-siblings, etc.
interactions with parents, stepparents, foster parents, etc.
• Structure of family (persons, relationships, communication, etc.)
generational boundaries
coalitions
• Family experiences during childhood and adolescent years
parenting styles experienced
communication styles and patterns
memories in the family setting
family trauma (history of abuse, witnessing domestic violence)
• Parental family background
parental family trees
parental family experiences
parental experience of childhood and adolescent trauma
parental medical and psychiatric history
• Current interactions with family of origin
• Genogram or family genealogy (optional)

Family History- • Identification of nuclear-family members in client’s adult life

Nuclear Family • Nuclear-family interactions
interactions with significant others (SOs) and former SOs
interactions with children, stepchildren, foster-children, etc.
interactions with family of SOs
• Structure of family (persons, relationships, communication, etc.)
generational boundaries
coalitions
• Nuclear-family experiences
parenting styles exercised with own children
memories in the family setting
family trauma (domestic violence, perpetration of abuse)
communication styles and patterns
• Functionality of the family

Sexuality . Sexuality in current intimate relationship (quality, frequency,

enjoyment, compatibility)
. Sexuality in other relationships (quality, frequency, enjoyment,
compatibility)
• First sexual experience (as a possible lead-in to sexual abuse)
Table 5-4 (continued)

Inquiry Area Questions to Be Answered

Sexuality (continued) • Later sexual experiences (quality, frequency, enjoyment,

compatibility)
• Masturbation
• Sexual abuse (incest, molestation, rape)
perpetrator(s)
specifics about the abuse (type, form)
age, frequency, and duration
events surrounding the abuse (e.g., where, when, threats made)
presence of a protector/confidant
Social History • Number and description of close friends (past and current)
• Acquaintances and colleague relationships (past and current)
• Interests, hobbies, recreational activities and interests (past
and current)
• Number and level of involvement in community groups (e.g.,
environmental-protection groups, sports leagues, special-interest
groups, clubs, professional associations)
• Religion and spirituality, including church memberships
• Sociocultural issues
socioeconomic variables
cultural background and world views
ethnic background and minority status
level and context (forced versus voluntary) of acculturation
Professional History • Description of current employment
• Career plans ahd aspirations
• Jobs and/or occupations in the past
Academic History • Adult academic or vocational preparation background
degrees Or certificates
performance (i.e., grades, level of success)
problems (e.g., learning disabilities or physical impediments)
• School (Kto 12) background
graduation
performance (i.e., grades, level of success)
problems (e.g., learning disabilities, peer relationships)
Health History • Developmental issues
mother’s pregnancy (i.e., in utero development and exposure)
birth information
developmental milestones
• Previous mental-health treatment
prior therapy or counseling
prior psychological testing or assessment
school and vocational assessments
• Medical trauma (injuries, accidents, head injuries; recent and past
for all)
• Physical health
current severe diagnosed illness
past acute illness
date, circumstances, and findings of last physical examination
• Name of physician and other health-care providers
• Hospitalizations, recent and past
• Current medical treatments other than medications
Substance Use 1 Prescription drug use (type, recency, frequency, amount)
• Over-counter drug use (type, recency, frequency, amount)
• Use of legal drugs, alcohol, tobacco products, caffeine (type,
recency, frequency, amount)
• Use of illegal substances (e.g., marijuana, cocaine, amphetamines,
 QUESTIONS TO ENCOURAGE COMMUNICATION 153

Inquiry Area Questions to Be Answered

hallucinogens, barbiturates, inhalants) (type, recency, frequency,

amount)
• Family history of substance use
medications (e.g., prescription and over-the-counter)
legal drugs (e.g., alcohol, tobacco, caffeine)
illegal substances (e.g., cocaine, inhalants, marijuana)
issues related to adult children of substance users
Nutrition • Daily food intake, exploring timing and quantities for breakfast,
lunch, dinner, snacks, and desserts
• Special diets
diets for physical illnesses (e.g., for heart or cardiovascular
disease)
vegetarian diets
macrobiotic diets
• Daily liquid intake, exploring timing and quantities (water, juices,
soft drinks, hot drinks)
• Daily exercise routine
• Awareness of nutrition and exercise needs
• Inappropriate use of food (e.g., under- or overeating; bingeing and
purging)
• Inappropriate use of exercise
• Family attitudes about foods, liquids, and exercise

CLINICIAN: This may seem picky, but how big was the bag and did you
have anything on it, like butter or salt?
CLIENT: It was one of those microwave bags, just a standard portion, and
it was buttered, too. I also always add a little bit of Parmesan cheese.
CLINICIAN: Okay, so let me summarize what we have so far. You some¬
times eat breakfast, you never eat lunch, you eat a solid dinner every day,
and you have a snack in the afternoon. Does that capture it?
CLIENT: Yes.
CLINICIAN: When you say you make sure you eat a solid dinner, what
does that mean?
CLIENT: Oh, I mean I eat a big meal. Usually something with a vege¬
table, meat, and generally I top it off with a nice dessert. I really like
food, I just don’t have time during the day to eat. So then I really treat
myself in the evening.
CLINICIAN: Tell me about a couple of typical dinners that you ate this
week. If you don’t mind all the detail, I’d like to know exactly everything
that you ended up eating, including how much and at what time.
CLIENT: Well, let’s see. . . . Yesterday evening I had steamed broccoli,
some rice, and a chicken breast. Then for dessert I had a piece of apple
pie. I baked it myself the day before. I use pretty good ingredients, like I
don’t use white sugar, only honey and I use whole wheat flour instead of
the white stuff.
CLINICIAN: Can you give me an idea of the size of your servings?
CLIENT: Well, I had a couple of crowns of broccoli and probably a cup of
154 CHAPTER FIVE

Skill Development Recommendations

Recommendation 5-4 Using Table 5-4, answer the structured questions

that are generally addressed by an intake interview. What are you learning
about yourself from this exercise? What are you learning about the depth and
breadth of an intake interview as you do this exercise? How much time may
such an interview require? How do you believe clients feel when they are
asked to answer these questions? Do any areas appear more difficult to inquire
about than others? Do any areas strike you as more difficult to answer?

Recommendation 5-5 Choose a topic area of therapeutic interest (for

example, childhood abuse, intimate relationships, suicide history). Outline the
questions you would want to have answered to feel satisfied that you know
everything about a client in this area. Once you have covered all content,
try to anticipate the likely order in which the questions may be presented to
a client. Evaluate each question for possible pitfalls.

rice. The chicken breast was actually pretty small. I take the skin off and
I cut any fat away.
CLINICIAN: And how big was the slice of apple pie?

CLIENT: Well, now, that’s a different story. I love sweets. It was

actually more than a slice. It was more like half a pie. (Session continues
from here.)

This transcript shows the importance of not only asking very detailed ques¬
tions during a systematic inquiry but also asking relevant follow-up questions.
In several instances in this exchange, had the clinician not asked follow-up ques¬
tions, she would have missed important details (such as the size of the apple
pie). Despite the level of detail requested from the client, there did not appear
to be any defensiveness on the part of the client regarding this difficult topic
area. This is perhaps best attributed to the fact that the clinician paid careful
attention to maintaining rapport with the client. The introductory statements,
the expressions of understanding, and a caring and concerned voice all con¬
tributed to a sense of support and caring during this long systematic-inquiry
session. In fact, only with this kind of sensitivity will a client tolerate systematic
inquiries which otherwise can turn tedious or intrusive.
 CHAPTER

Response Types

Verbal Communication
and Client Disclosure

Sensitive expression, entailing carefully chosen words

spoken from the heart, has the power to move people
to tears or laughter—to inspire action that can change
the world in ways larger or small.
Dan Millman, 1993, p. 50

Once clinicians have mastered the necessary attending and listening skills, are
capable of communicating nonverbally, and have learned skillful questioning,
they are ready to tackle the next important communication skill that enhances
the therapeutic exchange: responding to the client. Although attending, listen¬
ing, and questioning are necessary for a positive client-clinician interaction,
they are not sufficient. Clients also need to receive feedback about their ver¬
balizations, a process that requires caring and accurate responding on the
counselor s part. This helps the client feel heard and keeps communication and
disclosure going. It serves to explore and clarify content expressed by the client
for the clinician. In other words, the responding process serves to further clar¬
ify and develop the communication in which the client has already engaged.
The focus of therapeutic responding is not on clarifying meaning for the
client (that is, on the creation of insight about why a client is feeling, or behav¬
ing, or blinking in a particular manner). It is not to be confused with interpre¬
tation or confrontation, or any of the other affective and cognitive awareness
skills that are concerned with seeking explanations and meaning (or purpose of
thought, behavior, and affect). Instead, the basic response types most relevant
to communication and disclosure serve their primary purpose by clarifying in¬
formation/or the clinician. Additionally, responding skills are designed to help
the client feel heard and listened to. This is achieved by feeding back informa¬
tion received from the client, not to clarify or explain underlying meaning, but
to allow the client simply to recognize personal affect, thought, and behavior,
and to realize that the therapist has been listening attentively and openly. The

155
156 CHAPTER SIX

most important response types for the mental-health-care provider to master

include encouraging phrases, restatements and paraphrases, reflections, and
summarization. Embedding questions into these interventions can further en¬
hance their utility.

Encouraging Phrases

Encouragers, or encouraging phrases, are the simplest, and yet perhaps the most
important interventions clinicians can use to facilitate the continued commu¬
nication and disclosure of a client. Encouragers are designed to keep the client
talking about a given topic, to explore an issue in a manner that has depth as
well as breadth. The clinician using encouragers adds nothing new, suggests
nothing new, offers no interpretations, and does not attempt to lead the client.
In using encouragers, the mental-health-care provider merely encourages the
client to elaborate and explore what is already being talked out. There is no
suggestion to the client that a different topic should be broached; instead, en¬
couragers indicate to the client that the clinician is intensely interested in what
the client has to say and that the clinician would like to receive more informa¬
tion about the current topic. The power of these simple interventions must not
be underestimated. Encouragers are a potent technique to keep the client on
a topic and to suggest the importance of its in-depth exploration. Encouragers
must be used wisely. Used incorrectly, they may inadvertently serve to rein¬
force verbalizations that are off the point, rambling, or otherwise irrelevant or
nontherapeutic. Thus, clinicians need to learn to use encouragers in a discrim¬
inating fashion, applying them when truly interested in additional information
about a topic of relevance, and suppressing them when they want to encourage
clients to switch topics.
Encouragers, once learned, can become somewhat habitual and reflexive.
Using an encourager in a nonthinking, reflexive manner can get in the way when
a client is talking about a topic that is less than relevant to the issues at hand.
During those times encouragers need to be suppressed to communicate to the
client that it is important to move on.
There are four primary categories of encouragers. First, there are non¬
verbal signs that encourage a client to keep talking. Such nonverbal signs consist
of leaning forward, nodding one’s head, or raising an eyebrow. Second, simple
repetition of a word or phrase the client utters often communicates to the. client
to keep talking. Third, semiverbal encouragers, which are often combined with
nonverbal encouragers, consist of expressions such as “uh-huh,” “oh,” “aha,”
and so forth. Fourth, a simple phrase that requests more information is also
considered an encourager. Examples of such expressions are “And then . . . ?,”
“Like what?,” or “Tell me more.”
 RESPONSE TYPES 157

Sample Transcripts for Encouragers

Illustration One
CLIENT: I really have a hard time with this relationship. It seems to be
overwhelming at times, because I need some freedom that my friend just
does not want to grant me. I’m not sure what I would like to do but I
know I need to change something.
CLINICIAN: Change something? (repetition encourager)
CLIENT: Yes, I have had a sense of wanting to make a change in my life.
Maybe it’s not even just the relationship. Maybe I’m ready for a major
move in my life in general. But I am not really clear about that. . . .
clinician: Tell me more. (phrase encourager)
CLIENT: I guess I feel stagnant and really don’t know where to turn with
these feelings. Sometimes it’s very depressing and it feels as though I
have nobody to talk to.
clinician: (leans forward) uh-huh . . . (semiverbal encourager)
CLIENT: Yes, I have felt like that at many points in my life; like I have
nowhere to turn. I guess I have trouble making decisions about changes
in my life. That is true for my relationships and for any other events that
are going on.
CLINICIAN: (nodding) (nonverbal encourager)
CLIENT: There have been so many times in my life that I felt stuck, or
stagnant. Somehow I always made it through, though, in the end. I guess
what I have to do is just figure out how I did it before.
CLINICIAN: (now moving beyond encouragers) So you believe this is not
just about your relationships then?

Illustration Two
CLIENT: Sometimes I think that I am going crazy. Its like this thing
comes over me—a black cloud or something. And then I’m not myself
anymore. . . .
clinician: Not yourself anymore? (repetition encourager)
CLIENT: Yeah. I get so mad I could jump out of my skin, like I want to
scream and rant and rave. . . .
CLINICIAN: (leans forward, nodding her head) (nonverbal encourager)
CLIENT: Well, you know, just jump up and down, throw something and
just plain throw a tantrum like a little kid. I used to do that, you know,
when I was little. My parents still talk about it—I was a little monster. . . .
CLINICIAN: Really . . . ? (phrase encourager)
CLIENT: Yeah, I’d hit my little brother, I’d throw myself on the ground
in the grocery store—just would embarrass my poor parents to death. It
really seems unreal, doesn’t it?
CLINICIAN: Hmm, unreal? (semiverbal with repetition encourager)
158 CHAPTER SIX

Skill Development Recommendations

Recommendation 6-1 Start paying attention to how you encourage people

to speak in day-to-day interactions with friends and family members. Once
you have a clear idea of how much you are currently in the habit of using en-
couragers, make it a point to begin to use at least one of each type of encour-
ager in each conversation you have from now on. How does this practice ap¬
pear to affect your interactions?

CLIENT: Yeah—like another me takes over.

clinician: (moving beyond encouragers now) Help me understand that
“another you”?

These brief client-clinician interactions demonstrate how the use of en¬

couragers can facilitate the exploration of a topic in some depth. Simply through
the use of nonverbal signs and the repetition of a few simple phrases, the coun¬
selor was able to move the clients to an important conclusion about the topic
at hand or to continued disclosure. The use of encouragers in this way is positive,
as it allows the client to supply all the content of the conversation. The clinician
did not interject any interpretations or suggest any direction in which the client
should head. Instead, the counselor was merely curious to find out more about
the issue the client was discussing, giving each client the leeway to take the
topic to wherever it needed to go from the client’s perspective. The choice of
encouragers allowed the clients to move through the topic area in a way that
was most meaningful to them.

Restatements and Paraphrases

Restatements and paraphrases are very similar to each other in structure and
purpose. Both are repetitions of content expressed by the client. They are set
apart from reflections by the feature of merely feeding back to the client the
clinicians perception of content or topic area the client expressed. Reflections,
on the other hand, not only repeat content but also attempt to crystallize and
feed back underlying affect or hidden meaning the mental-health-care provider
derived from the client s communication. Restatements and paraphrases share
at least three primary purposes. First, they convey tracking and focusing, along
with a sense of hearing what the client is talking about. Second, they serve as a
means to double-check or clarify for the therapist that she or he is truly un¬
derstanding the content and is forming the correct understanding or percep-
 RESPONSE TYPES 159

tion of the clients attempted communication. Third, they can be used for one
reason or another to highlight something the client has said. They may high¬
light an aspect of a client s communication to express its importance, point out
its confusing nature, make it more concise, or clarify or crystallize it. Notably,
neither restatements nor paraphrases are used to attempt to feed back to the
client a client s understanding of underlying affect or possible hidden meanings.
In using restatements and paraphrases, a selective process takes place in
that the clinician decides which idea or content to hone in on for repetition.
These choices must be made wisely and are best decided upon with the fol¬
lowing goals in mind:

• Does the clinician wish to clarify an important point?

• Does the clinician want to reinforce something that was said?
• Does the clinician want to distill out a theme or pattern?
• Does the clinician want to double-check an understanding of an issue?
• Does the clinician want to highlight something of special importance?
• Does the clinician mean to explore any one point in particular in more
detail?

Sometimes the choice about what to restate or paraphrase is also made with
the opposite goal in mind. Namely, at times a counselor may emphasize one as¬
pect of the communication to help the client shift gears or refocus attention. In
other words, the clinician may choose one point over another to extinguish or
discourage a certain topic so as not to allow the client to bring in too many things
at once or to avoid an important therapeutic issue. Thus used, restatements and
paraphrases become powerful tools in steering a conversation. Restatements
are also useful if a client s thoughts are racing and the clinician wants to make
an intervention that will help the client slow or calm down a bit.
Since the structure of restatements and paraphrases is very similar, they may
at times be difficult to differentiate from one another. Both are succinct repe¬
titions of something the client has said. Restatements are similar to encouragers
and differ from them primarily in the length of the verbalization expressed by the
clinician (being somewhat longer and more thorough than an encourager). Re¬
statements capture the essence of one simple item talked about by the client.
Restatements are formulated using the clients words. That is, the clients lan¬
guage is used to feed back the one important content issue derived by the clin¬
ician from the client s communication. This feedback is phrased not in the ther¬
apist s language, but merely repeats the idea in the client s words. Restatements
are sometimes referred to as “parroting.” This label serves to point to the poten¬
tial danger that lurks in the overuse or simplistic use of restatements. The fact
that restatements use the clients language may mislead the less-sawy coun¬
selor into thinking that exact repetition of a client statement is in order. Such
exact repetition can be a hindrance to rapport as the client may feel mocked. It
is for that reason that paraphrases are generally preferable to restatements.
160 CHAPTER SIX

Often restatements begin with an innocuous introductory stem such as

“What you’re saying is ...” or “What you are telling me is . ..followed by the
repetition of the most important point gleaned by the counselor. However, re¬
statements can also be phrased with no stem at all, simply feeding back the main
point, such as “You’re having second thoughts about getting married.” A brief re¬
statement can be virtually indistinguishable from a simple phrase encourager.
For example, rather than the repetition of the full sentence just demonstrated,
the clinician may have chosen to use a simple phrase encourager such as “Sec¬
ond thoughts?” The choice of using a full sentence (a restatement) versus a
phrase (an encourager) has more to do with the proximity in time of the repeated
phrase or statement to the original verbalization of the client. If the client just
finished saying the phrase or statement the clinician wants to highlight through
repetition, a simple phrase will usually be indicated. If the phrase or statement
was not the last one uttered by the client, that is, if the counselor wants to return
to something the client said a little while back, a restatement generally will work
better.
The structure of a paraphrase is similar to that of a restatement. A para¬
phrase contains a clarifier that expresses to the client that the clinician is ex¬
pressing what she or he thinks was said by the client. This clarifier can take the
form of an introductory stem or a closing stem. An introductory stem that ex¬
presses that the clinician’s perception of what has been said is being reflected
back may be as follows:

• “What I’m hearing is . . .”

• “It sounds to me as though . . .”
• “What I hear you saying is . . .”
• “What rang a bell for me . . .”
• “As I see it. . .”
• “My view of this is . . .”
• “The picture I’m getting from what you are saying is . . .”
• “My sense is . . .”
. “I felt...”
• “I sense you tried to . ...”

Review of these introductory stems shows that they give the counselor an
opportunity to match the client’s verbal style by using sensory words that
match the client’s primary choice of sensory modality. The clinician may choose
words in the stem such as “see” or “view” for a client who processes visually,
“hear” or “sound” for a client who processes auditorily, or “feel” or “sense” for
a client who processes ldnesthetically. This choice of words helps the clients
perceive that their language has been received and restated by the clinician. A
counselor may also choose to use a closing stem instead of an introductory one.
Closing stems follow the paraphrasing of the main idea and may be as follows:
 RESPONSE TYPES 161

. • “Am I hearing that correctly?”

• “Does that sound right?”
• “Am I getting the right picture?”
• “Am I seeing things the way you do?”
• “Is that close?”
• “Does that capture it?”
• . ?” (questioning pause)

In a paraphrase, the clinician tries to communicate the content that was

provided by the client, again focusing on one primary idea, but using the coun¬
selor s own language. In other words, in choosing a paraphrase rather than a re¬
statement, the mental-health-care provider runs less of a risk of being perceived
as parroting or mocking the client because the client s words are not merely re¬
stated. Because of this different word choice, however, it is important to add to
the paraphrase the introductory or closing stem that clarifies that the clinician
is feeding back information as seen from her or his perspective. This is the pri¬
mary differentiating factor between a restatement and a paraphrase. A restate¬
ment merely repeats what the client has said for clarification purposes. The
paraphrase moves one step beyond that by challenging the client to hear and
understand the clinicians language. The paraphrase, by virtue of being stated
in the counselors language, is more prone to reflect the counselors bias in un¬
derstanding an idea expressed by the client. In that sense, a paraphrase can be
viewed as an intermediate step between a restatement and a reflection. The
choice of a paraphrase versus a restatement is based on at least two decisions.
First, as a general rule paraphrases are preferred because they do not run the
risk of mocking the client. Second, paraphrases tend to be preferable if the
mental-health-care provider wants to communicate very clearly that the nu¬
ance of what the client attempted to communicate was captured. In other
words, the clinician has a way of stating the important thought in a manner that
enhances, clarifies, highlights, or crystallizes the clients expression. The client
feels more deeply understood and heard than with a mere restatement. There
are times, however, when the clinician wants to do just the opposite. That is,
sometimes a counselor wants to use a clients words to make sure the client
hears what they just expressed and how they expressed it. This choice of re¬
statement often represents a challenge to the client and tends to be used later
in treatment, after firm rapport has been established. Illustration Three below
presents such a purposeful restatement, whereas Illustrations One and Two
demonstrate the difference between a restatement and a paraphrase.

Sample Transcripts for Restatements and Paraphrases

Illustration One
CLIENT: What happened then was even more embarrassing. I turned

away and she started to scream at the top of her lungs in the middle of
162 CHAPTER SIX

the street! Can you believe it?! She just stood there with everybody
around and cussed at me. How could I have ever loved someone like that
who has no social skills? Am I really that dependent that I would just go
out with anyone who says, “Hey, you’re cute?” I am really shaken up by
this. . . . What does it all mean and what do I do now?

Restatement Response Option

CLINICIAN: You really wonder about being dependent. . . .
CLIENT: Yes! What’s wrong with me? This is obviously not the first time
I have picked a woman like that. Remember, I told you about. . . .

Paraphrase Response Option

clinician: What it sounds like to me is that you are really wondering
about being emotionally needy right now. (rephrasing “dependent” into
“emotionally needy”)
CLIENT: Yes, I guess that’s it. I feel like I need someone around all the
time. I get so lonely when I’m alone that I’d rather be with anyone than
no one.

Illustration Two
client: I am not sure where to start this week. So much has happened
that my head is spinning. I can’t tell you how much I’ve been looking
forward to this session—I really need it today! But now that I’m here
I don’t even know where to start. . . .

Restatement Response Option

CLINICIAN: So much happened that it’s hard to start today!
CLIENT: Yeah—confusing, isn’t it. Oh well, I guess I’ll start by telling
you about...

Paraphrase Response Option

clinician: You’re on overload and that makes it hard to sort out what is
the most important thing to deal with first. Is that it? (rephrasing “head is
spinning” into “being on overload” and “what to start with” into “the
most important thing to deal with”)
CLIENT: That’s it exactly. I’m on overload! Just too much for one human
being to deal with all at once ...

These examples serve to clarify the minor differences between restate¬

ments and paraphrases. Clearly, a paraphrase adds something unique by the
clinician. Paraphrases represent more of a belief or leap of faith that the coun¬
selor has a clearer way of phrasing what the client is really trying to say. Often,
when successful, and as demonstrated in the above examples, a paraphrase will
elicit a relieved response from the client. The person feels heard more deeply
 RESPONSE TYPES 163

when the clinician is able to rephrase things just so. However, either response
from the clinician helps the client move along and get focused.

Illustration Three
CLIENT: My mother always said that if I don’t have anything nice to say
I should just keep my mouth shut. But in a strange way that made me
wanna do just the opposite. So I find myself saying things a lot that I later
regret. Like yesterday, I was mad at Jackie and I told him if you don’t like
my rules, just move out! And you know what? He did. I can’t believe it.
He’s fifteen and he packed up and moved.
clinician: Moved where?
CLIENT: To my mother’s, of all places!! She thinks I’m a lousy parent so
when Jackie called her she told him he could live with her because she
knows I’m a loser!
CLINICIAN: She said you’re a loser?
CLIENT: Well, no—I’m saying she took him in because I’m a loser. . . .
clinician: You’re a loser. . . . (purposeful restatement)
CLIENT: Yes, I am. I’ve shown that once again, don’t you think?
CLINICIAN: You have once again shown that you are a loser. . . . (purpose¬
ful restatement)
CLIENT: (wavering) Well... I think I have . . .
CLINICIAN: Listen to yourself—I’ve shown once again that I am a loser!
CLIENT: When you put it that way, it does sound a little harsh. (The clini¬
cian did not put it that way, the client did; however, this is no time
to argue.)
CLINICIAN: Go with that. (phrase encourager)
CLIENT: Well, I did what I had to—I am at the end of my rope with
Jackie. After he got caught breaking and entering last month, I’ve been
trying to be a little stricter. It’s just so hard, with Mother undermining
me like she does.
CLINICIAN: Like she does now?
CLIENT: Yes! . . . (Session goes on from here.)

Here a purposeful restatement was chosen to demonstrate to the client

how she uses words in a self-defeating manner. This type of restatement clearly
has a therapeutic purpose and goes beyond the usual purposes of restatements.
It does not just seek to keep communication or disclosure going; it steers the
client toward insight. This type of work will generally occur later in treatment
after sufficient rapport has been established, but occasionally may be used
even early on if the clinician feels the client is able to tolerate this type of in¬
tervention. As an aside, this example also demonstrates the targeted use of clar¬
ifying questions, a matter that was discussed in detail in the previous chapter.
Finally, it should be noted that oftentimes, clinicians with experience will
actually mix restatements and paraphrases in their work with clients. It is a
164 CHAPTER SIX

Skill Development Recommendations

Recommendation 6-2 Start paying attention to how you respond to people

in day-to-day interactions with friends and family members. Once you have
a clear idea of how much you are currently in the habit of using restatements
or paraphrases, make it a point to begin to use at least one of each in each
conversation you have from now on. How does this practice appear to affect
your interactions?

Recommendation 6-3 For each client statement that follows, write out a
restatement and a paraphrase:

• I have been incredibly distracted by everything that’s going on. It’s very
confusing to try to figure out what to deal with first.
• I don’t think I can keep going like th is. If something doesn’t change in this
relationship I’m going to have to get out just to save my son and myself.
We can’t take this anymore. . . . (weeps)
• I am really fed up with you. You are a quack, you know! Did you buy
your degree or something?
■ I don’t think I’ve ever been more scared! It was one of those situations
that you have nightmares about and you wake up and think “Oh my God,
I’m so glad this wasn’t real.” And now here it is .. . It’s terrifying. . . .
• I am lonely . . . all alone in the world. First my husband dies and now my
daughter. Mothers are not supposed to survive their children. What am I
going to do? It’s too much. . . .
• I feel like giving up. No one would notice anyway. . . . No one would
care. ... I have nothing, I am nothing. . . .
• I am not only happy, I am ecstatic. I have never felt better. That promo¬
tion came just at the right time!

good idea for die novice, however, to practice the pure forms first for a while
to get a good sense for each form of verbalization. The Skill Development Rec¬
ommendations above will help with this task.

Reflections

Reflections are a way in which the clinician can repeat back to clients what was
said, while bringing out a metacommunication that was perceived in the com¬
munication. Reflections move beyond restatements and paraphrases in that
 RESPONSE TYPES 165

they do not just restate content, either in the client s or the clinicians words,
but add an underlying message or feeling that was detected by the counselor
even though the client may not have said it directly. For a reflection to be pos¬
sible, the mental-health-care provider has to listen for such subtle communi¬
cations, using all the important listening skills outlined previously. Attending to
nonverbals is particularly helpful in this regard.
Reflections encourage broader self-exploration by the client and tend to
induce a more intense experience, often by connecting verbal and nonverbal
communication. They emphasize a focus on affect and help clarify hidden mes¬
sages that are either consciously known or unknown to the client. The purposes
of reflections thus can be summarized as follows:

• help the client feel understood on a deeper level

• deepen the relationship between client and clinician
• encourage freer expression of feelings
• begin to assist the client in managing affect
• make covert context or meaning overt
• uncover hidden messages

To structure a successful reflection, the clinician must first listen atten¬

tively and deeply for the hidden affect and/or message the client is convey¬
ing. To listen for affect the clinician attends to feeling words, looks at non¬
verbal expressions of the client, and pays attention to the many emotional
subtones during the client s conversation. To find the hidden messages of the
client, the clinician must learn to read between the lines. This can often be
accomplished in ways similar to listening for affects in that the counselor care¬
fully attends to nonverbals and similarly indirect expressions while the client
speaks. Finding affects and hidden messages may sound like an overwhelm¬
ing task to the beginning counselor; however, it is actually quite an easy feat
once a client is well known to the clinician. All clients have ways of express¬
ing the unsayable that become well recognized by the counselor once the
client has been seen for awhile. It is not helpful to be so uptight about learn¬
ing the hidden message that the clinician becomes preoccupied; instead, it is
best to just use all the careful attention and listening skills available and then
to trust intuition. Clients will not be hurt by the occasional reflection that is
off target. Reflections will also be used to express empathy for the client. Thus,
the chapter on empathy will help novice clinicians further deepen their reflec¬
tion skills.
Once the clinician has gleaned an important affect or hidden message, at¬
tention needs to be given to how to phrase the reflective statement. First, as for
paraphrases, it helps to open or close the reflection with a stem that reflects
that the clinician is expressing an impression. The same introductory or clos¬
ing stems used for paraphrases can be used for that purpose. A questioning
166 CHAPTER SIX

pause at the end of a statement may be an appropriate closing stem as well,

since it signals to the client some openness on the clinicians part to be cor¬
rected if the message was off target. Cautiousness in how the clinician speaks
can take the place of a closing or opening stem. How the reflection is delivered
can convey the same message as the verbal opening or closing stem. A cautious,
caring voice can reflect the same concern and openness to being corrected as
a verbal expression of the same through the stem.
Second, the clinician summarizes the affect or hidden message that needs
to be fed back to the client. This reflection needs to be succinct, clear, meaning¬
ful, and accurate. It is also important to match the affect words chosen in the
summary to the actual affective state of the client. In other words, it is not enough
to identify the correct affect, but it is best to also evaluate and correctly reflect
its intensity. For example, if a client expresses anxiety, the clinician can speak
of “unease,” “trepidation,” “fear,” or “panic” (or many others), depending on the
level of anxiety expressed. Using the word “panic” when the client is evidenc¬
ing mild anxiety would be a mismatch; the right affect is identified but at the
wrong intensity. Similarly, speaking of “despair” when the client feels discour¬
aged is in the right ballpark, but again at the wrong intensity. The chapter on
affective processing will give further guidance about matching affect intensity.
Third, a good reflection adds a context for the affect or hidden message
that is reflected back. This context may be as simple as identifying when the af¬
fect is occurring (for example, right now, in a certain situation) or what sug¬
gested the hidden message to the clinician. Examples of context statements can
be as simple as “You were angry when he did that” or “You seem angry right
now, just talking about this”; or the context can be a bit more complex, as in “It
sounds to me as though you are getting quite worried about this impending
marriage [note the complexity of context implied here] and that you are land
of surprised by your own misgivings right now. ” To summarize, a reflection is
structured around a stem (introductory or closing), an affect or hidden mes¬
sage, and a context for the affect or message. Despite the fact that these three
components are covered, the reflective statement needs to stay as succinct and
clear as possible. It can use a combination of the client’s words and the clini¬
cians own language, combining elements of restatements and paraphrases.

Sample Transcripts of Reflections

Illustration One
CLIENT: Every evening we go through the same ritual. I ask her to go to
bed; she starts to cry. I am at the end of my rope with that child. She is
eight years old and has no respect for my authority. My other kids aren’t
like that... and she’s the oldest; oh my goodness, I can’t even think of it....
clinician: I think what I’m hearing are really two worries. Number
one, you are overwhelmed with the struggle every night (reflection of af-
 RESPONSE TYPES 167

feet). Number two, you are afraid that Jeannies behavior may rub off on
the little ones. . . . (reflection of affect and hidden message)
CLIENT: Yes. They look up to her so much—and they are like her in a
lot of ways. Right now they still listen to me but what if I lose control
over them too?! What am I supposed to do? I am all alone in this bloody
town; first my husband drags me here and then he just gets up and leaves
(igetting agitated); I just don’t know what to do. . . . (starts to sob)
CLINICIAN: Its just all too much right now—with so many overwhelm¬
ing feelings and problems you feel paralyzed and powerless. (reflection
of affect)
CLIENT: (quietly sobbing) Yes, and no one there to lean on. . . .
CLINICIAN: (soft voice) You feel so alone. . . . (reflection of affect)

Illustration Two
CLIENT: (to the clinician) I have had it with you. You just ask and ask and
ask and you never give me any answers. I came here because I wanted
someone to help me; all you do is bother me with stupid questions! What
is your problem?!
CLINICIAN: You are not getting what you hoped for ... ? (paraphrase
bordering on reflection)
CLIENT: Hell NO. That’s the first smart thing I’ve heard from you!
CLINICIAN: You sound very frustrated with me. (reflection of affect; note
the nondefensiveness of the clinician)
CLIENT: Duh! I came here because of my wife and now here you are
acting just like her! I guess it’s just women. You’re all the same—and you
make no sense to a normal guy like me.
CLINICIAN: So women are a puzzle to you, is that right? (reflection of
underlying message)
CLIENT: Oh my—YES. I have no clue how you people think. You are
just wired in a whole different way. I think someone left the logic out
of you-—or maybe women are just there to annoy men; maybe that’s it.
(pleased with himself now) Women are the root of men’s problems but
then WE get the blame!
CLINICIAN: What I think I’m hearing is that you feel you do what you
can, but in the end you get the blame for the trouble between you and
your wife? (reflection of underlying affect)
CLIENT: Yup! She ends up being the one who cries and then I feel like
shit! And then I just run out—I just have to get away from her then.
CLINICIAN: It’s like you feel bad for her and then all you know to do is to
get out of there. . . . (reflection of underlying message)
CLIENT: Yeah—I mean, I’m no monster. I hate it when she cries. And
then I wonder what did I do?
168 CHAPTER SIX

Skill Development Recommendations

Recommendation 6-4 Start paying attention to whether you reflect what

people sau in day-to-day interactions with friends and family members. Once
you have a clear idea of how much you are currently in the habit of using re¬
flections, make it a point to begin to use at least one in each conversation you
have from now on. How does this practice appear to affect your interactions?

CLINICIAN: (cautiously) Almost sounds like some guilt. . . (reflection

of affect)
CLIENT: (quietly now) I suppose so. Can you help. . . .

These examples show that simple reflections of affect and recognition of

underlying meaning or messages are powerful ways to help clients feel heard,
understood, and cared for. In each of these examples the simple act of reflecting
led the client to a deeper level of self-understanding and disclosure, moving the
counseling in powerful new or more meaningful directions. Reflections move
the client away from the surface of issues right into the heart of their experi¬
ence. Such reflections take skill, good timing, and expressed caring. The tone
of voice with which they are delivered can make a big difference in whether the
client feels heard, understood, and cared for—or criticized and challenged.

Interfacing Response Types

The fact that the structure of restatements, paraphrases, and reflections is so

similar correctly suggests that these three types of responses to clients are
closely related. In fact, it is not too unlikely that some statements counselors
make cannot be cleanly classified as one or the other. This is no problem. The
main issue for clinicians is to learn all three of these types of responses and
then to begin to use them freely and interchangeably. There are some occa¬
sions when one type of response may be superior to another. The most impor¬
tant issues are to help clients feel heard and understood, to engage the client
in further self-exploration and disclosure, and to let the client know that the
clinician is listening attentively, clearly, and in an unbiased way.
A few general guidelines about when to use restatements versus para¬
phrases versus reflections follow. If clinicians feel comfortable adding an affect
 RESPONSE TYPES 169

6r identifying a deeper meaning, a reflection may be used. If the clinician is un¬

certain where the client is going with a conversation, a restatement or para¬
phrase may be easiest as the counselor may not yet be clear about the underly¬
ing feelings. If a restatement feels too much like mocking or parroting to the
client, a paraphrase is the better choice. In fact, as a general rule of thumb,
paraphrases, when possible, are preferable to restatements, except in a few
very specific situations. Reflections tend to deepen the therapeutic relation¬
ship and as such are the most desirable of the three types of responses. It is im¬
portant to note that encouragers can be used throughout as well, as they can be
easily integrated with any use of restatement, paraphrase, or reflection. When¬
ever the sole purpose of the clinician is to encourage the client to continue talk¬
ing, disclosing, and exploring, a simple encourager will best serve the purpose.
Supplemented with the other response types, such interactions can be pro¬
foundly useful and therapeutic.

Guidelines for When Best to Use Which Response Type

• it is best to use a restatement over a paraphrase or reflection
. when it is important to emphasize the specific wording a client chose
• when it is therapeutic to slow a client down who is talking (too) fast or
whose thoughts are racing
• it is best to use a paraphrase over a restatement
. to feed back a simple content when no need exists to highlight specific
client word choices
. when the client is sensitive to being mocked or parroted
• when the clinician wants to use a particular word instead of the word
the client chose
. when the clinician believes it is an opportune time to begin to reframe
a content for the client
• it is best to use a paraphrase over a reflection
. if addressing affect would be premature (for example, because
insufficient rapport exists, because the clinician is not yet entirely cer¬
tain about the specificity or intensity of the affect, or because the client
cannot yet handle having the affect made overt)
• if revealing a hidden message would be premature (for example, be¬
cause the client is still utterly unaware of it, or because the client can¬
not yet handle that level of intensity in the session)
. if revealing the hidden message would be inappropriate (for example,
because the client is using the hidden meaning as a means of manipu¬
lating the clinician)
. when content is of greater importance than affect (for example, the
content is yet insufficient or unclear, or the content is contradictory)
170 CHAPTER SIX

• when affect tends to be overused by the client (for example, a client

who has strong histrionic tendencies and overemphasizes affect in day-
to-day life)
• it is best to use a reflection over a paraphrase or a restatement
• any time the clinician has enough information about and rapport
with the client to use the reflection accurately and in a therapeutic
manner
. it is helpful to use encouragers
• any time the clinician merely wants to keep the client talking, disclos¬
ing, or self-exploring
• interspersed along with all other response types

Sample Transcripts for Interfacing All Response Types

Illustration One
client: I have been thinking about my work situation a lot since we met
last week. I still don’t get what’s going on. I have really tried my best to
please Jennifer but it seems that no matter what I do or say, she gets an¬
gry or snaps at me. It’s very scary sometimes! Really makes me evaluate
everything I want to do before I do it and sometimes I don’t say what I
want to say because I just know there will be trouble. . . .
clinician: Sounds like in your confusion you end up walking on
eggshells . . . (paraphrase)
CLIENT: Yes; every step I take I have to wonder about when she’ll explode
again. I really can’t afford to get fired, you know. I have my family to sup¬
port since my husband is not due to graduate for another year and
a half. . . .
clinician: So, it’s more than just being worried about Jennifer blowing
up at you; it’s really about being scared of losing your job and leaving
your family hanging! (reflection of affect and paraphrase of content)
CLIENT: Yes, I guess that’s really it. I have worked there for ten years and
never had problems with a boss before. She got promoted only four
months ago and suddenly I’m in a panic. . . .
clinician: In a panic? (simple encourager)
CLIENT: Yes! I’m in a panic. I didn’t realize ’til you said it—but that’s
really what it is. It’s beyond worry. It’s not just a job that’s on the line; it’s
my lads, my husband, everything. . . . (looking terrified now)
clinician: Sounds like the problem has taken on a whole new dimen¬
sion for you?! (reflection of underlying message)
CLIENT: Yes. (beginning to cry now) I have to be the responsible one in
the family right now. I always criticized Greg for not getting along with
his boss, always told him he should just shut up and do as he was told.
I had no idea . . .
 RESPONSE TYPES 171

CLINICIAN: It really feels to me that you’re not just struggling with your
own work situation, but also with some guilt maybe over not having un¬
derstood Greg better when he was going through something similar?
(bold reflection of affect and hidden message)
CLIENT: Yes . . . (sobbing now)

Illustration Two
CLIENT: I really like the fact that she does not want children. There are
very few women that agree with me on that point and so I’m thinking
that I need to make sure that this relationship will work out.
CLINICIAN: It’s rare for you to meet women that agree with you there . . .
(restatement)
CLIENT: Yes; in fact several relationships have fallen apart because of
that. I am not willing to give on that particular issue. I do not want to
have children. The world is not a good place for them and it is over-
populated as it is.
clinician: Sounds as though you feel unbending about this issue.
(;paraphrase)
CLIENT: You bet.

CLINICIAN: You have let relationships go because of it. (finally catching

on to the most important message and using a restatement to communi¬
cate that)
CLIENT: Yes. Women don’t like it, so now that I found one who feels the
same way I think, I need to hang on to her.
CLINICIAN: You want to hang on to her but you don’t sound very excited
about this, (reflection of underlying affect [or rather lack of affect])
CLIENT: Well, I think it’s enough to agree on things. I don’t have to be
excited. . . .
CLINICIAN: You don’t have to be excited? (repetition encourager)
CLIENT: No. Excitement in relationships is overrated, in my opinion. The
main thing is that you agree on basic values. Romance fizzles anyway. . . .
clinician: Romance fizzles? (repetition encourager)
CLIENT: Oh yes. It’s just in the movies that people have passion and
excitement forever and ever.
CLINICIAN: Am I hearing that in your experience passion and romance
don’t last? (reflection of underlying message)
CLIENT: Yes.
CLINICIAN: Tell me more, (phrase encourager)
CLIENT: Well, I guess I have never had a relationship like the ones in
movies—You know, where couples swoon over one another or can’t wait
to grab each other. My relationships tend to be about talking about cur¬
rent events, news, maybe the stock market; they don’t really involve
much touchy-feely stuff.
172 CHAPTER SIX

CLINICIAN: You don’t swoon or touch much . . . (restatement)

CLIENT: I’ve never swooned! And I only touch when I have to. . . .
clinician: When you have to? (repetition encourager)
CLIENT: Yeah—you know, during sex.
clinician: So touch happens only during sex . . . (restatement)
client: Yes, basically.
clinician: Tell me more about that. (phrase encourager)
CLIENT: Well—I don’t know what more you want here. Like, I don’t like
to hold hands or kiss in public. I don’t rub her shoulders or play with her
hair. Does anyone do that in real life?
clinician: (shrugs shoulders, maintains questioning eye contact) (non¬
verbal encourager)
CLIENT: Yeah, I guess you’re right—I guess they do. I’ve seen people do
it. It always seems so fake though. . . .
CLINICIAN: Fake? (repetition encourager)
CLIENT: Oh, you know . . . like they do it because they’ve seen it done in
the movies, not because they really want to or like it. . .
clinician: You don’t like to be touched that way. . . . (mix of restatement
and reflection)
client: No—never liked it much. Much to my mother’s chagrin. She
was a touchy-feely type. Always wanted hugs and kisses and pats on the
back and on and on—I hated it.
clinician: Even when you were a child you didn’t like touch very
much . . . ? (paraphrase hordering on reflection of underlying message)
client: Right. Maybe it’s because she was doing too much of it. . . .
clinician: She? (repetition encourager to clarify)
CLIENT: My mother . . .
clinician: Tell me how she may have touched too much (mixture of
phrase encourager and restatement)
client: Well, I remember when I was really little, she would give me
baths a lot, and she took a lot of time with them, just rubbing and doing ...
I just remember feeling strange and wanting to get out of there. But she
was so insistent. When I got older she couldn’t hold me in there anymore,
so then she tried to get her groping in in other ways. . . .
CLINICIAN: Sounds like the kind of touch she used bathing you definitely
did not feel right to you? (reflection of affect)
client: No . . . (embarrassed now; looking away) I’ve never told anyone
this, but sometimes when she washed my penis, over and over again, I
would get erections. I guess I didn’t really understand what was happen¬
ing back then—I just remember feeling strange. . . .
clinician: (soft, caring voice) You say that back then you didn’t really
understand what was happening. . . . (restatement) (voice softer yet)
Do you understand now?
 RESPONSE TYPES 173

CLIENT: (quietly and tentatively, but with eye contact again) I guess so....
CLINICIAN: (gently and with caring) Tell me . . . (phrase encourager)
CLIENT: Was it sexual. . . (looks away again; suddenly overcome with
emotion)
CLINICIAN: (very quietly and gently) . . . abuse? (finishing his thought
for him; a nontraditionally phrased reflection of underlying message)
client: (looking up; nodding gently, starting to cry) (Session goes on
from there.)

These transcripts show how powerfully encouragers, restatements, para¬

phrases, and reflections can be combined to help move a client along in coun¬
seling. No interpretations were made at all with either client. The clinicians did
not draw on much material from prior sessions to understand and respond to
their clients, but merely focused on really listening to verbals and nonverbals
to glean their clients’ state of emotion and underlying context. Then that under¬
standing was simply restated, paraphrased, or reflected back to the clients. The
combination of feeling thoroughly understood and feeling supported by
preestablished rapport helped the clients open up to a new dimension of ex¬
perience and understanding of their current situations. The second illustration
also serves to show how much more difficult a client can be if she or he does
not have a reflective or affective style. Reflections work best with clients who can
deal with feelings or at least know how to express emotions. Clients who are
cognitive in their style will require more work in terms of getting them to a point
where they feel affectively connected to and supported by the clinician. Often
more encouragers, restatements, paraphrases, and reflections of underlying
messages are needed with such clients before reflections of affect are truly ac¬
cepted and heard.
Given that the response strategies of encouragers, restatements, para¬
phrases, and reflections are so commonly used together, it may be helpful to
compare and contrast them briefly with regard to their basic purposes, guide¬
lines for use, and general structure. This comparison is provided in very simple
form in Table 6-1.

Summarization

Summarization is a unique way of combining any or all of the techniques cov¬

ered so far in this chapter. It is used whenever the clinician wants to feed back
more than one idea, content, affect, or hidden message at a time. A summariza¬
tion can consist of a combination of restatements, paraphrases, and reflections
and is less succinct than any one of these strategies alone. Often summariza¬
tion is used at the end of a session to bring closure to what has been worked on.
Occasionally, summarization is used when a client has brought up numerous
174 CHAPTER SIX

TABLE

6-1 Comparison of the Primary Response Types

Response
Type Purpose of Use Guidelines for Use Structure

Encouraging • To elicit more content • Few restrictions on • Nonverbals to

statement • To encourage further when to use express interest or
disclosure • Repetition of a word
• To express interest in or
hearing more • Semi-verbals or
• Repetition of a simple
phrase
Restatement • To restate content • When emphasizing • Optional introductory
• To facilitate disclosure a client’s word choice stem and
and communication • When trying to slow • Restatement in
• To demonstrate a client down client’s words
listening
Paraphrase • To paraphrase • Can be used freely • Introductory or
content • Not used if a reflection closing stem and
• To facilitate disclosure serves better • Restatement in
and communication clinician’s words
• To demonstrate
understanding
Reflection • To demonstrate deep • Response of choice • Optional introductory
listening when trying to feed or closing stem and
• To feed back overt or back understanding • Expression of
covert affect • Not to be used with underlying affect or
• To feed back insufficient rapport hidden meaning or
underlying messages • Not to be used • Expression of affect
• To deepen rapport prematurely intensity and
and expressed caring • Not to be used with • Inclusion of a context
insufficient information

issues all at once at a quick rate, and the clinician wants to make sure that all the
important content areas and affects were heard and are fed back to the client.
Because of the greater length and complexity of summarization, this response
strategy is used with much less frequency than the other response types cov¬
ered in this chapter.
The structure of summarization varies widely depending on what response
types the clinician chooses to combine. Most generally, summarizations will
begin with some type of introductory stem or close with a closing stem, much
in the same form as discussed above. Then restatements follow for aspects that
meet the criteria or guidelines for restatements, paraphrases for feeding back
of content that meets the guidelines for paraphrases, and reflections as appro¬
priate given the level of information and rapport. In other words, the summa¬
rization follows all the guidelines about restatements, paraphrases, and reflec¬
tions outlined above and summarized in Table 6-1. It is best to keep even this
lengthier statement as succinct and clear as possible. A summarization is not to
 RESPONSE TYPES 175

be mistaken as an opportunity for a speech or monologue. Sometimes, it is a

good strategy to break summarizations into component parts, using closing
stems between components to give the client a chance to give feedback and in¬
put. Such summarizations become an almost collaborative effort between
counselor and client while closing a topic, rehashing several content areas, or
closing a session. Summarization is perhaps best explained via illustration.

Sample Transcripts of Summarization

Illustration One (End-of-Session Summarization)
CLINICIAN: Well, it is almost time for us to quit. We covered a lot of
ground today, and I think I’d like to recap some of the more important
points before we leave. I think maybe one important issue was that you
are still struggling with how to best deal with your work situation, but
you are getting closer to some idea of what to do. Does that capture it?
(reflection of affect and message)
CLIENT: Yeah, I think I am getting clearer. Maybe next week we can
wrap that up. (smiles)
clinician: Sounds great. (smiling as well) Then we may want to move
on to dealing with your relationship with Jesse because it felt to me today
that you had a lot of feelings about that and we only just scratched the
surface there . . . right? (reflection of affect and underlying message)
CLIENT: Yeah—I don’t much like the idea, but you are right—There is
a lot happening there, and I do need to look at why I get so angry at her
when she does just the least bit to challenge me. . . .
CLINICIAN: And then the last thing that comes to my mind is the fact
that we spent some time today looking at your relationships with your
parents and your recognition that there are some things you learned from
them that maybe aren’t helping you in your life right now. We need to
look at that some more, what do you think? (paraphrase and reflection of
affect and underlying message)
CLIENT: Oh, I know we do. You know, I’ve been avoiding that but you’re
right. It felt good just doing what we did today. So I imagine it really
would help to go back to that. . . . (smiles) Boy, I sure am glad we’re done
for today! (smiles some more)
CLINICIAN: I can understand that. Lots of good work! Alright then. I’ll
see you next week, same time, same place. (smiles and gets up) Take
care. .. . (opens door for client)
client: Thanks! Bye, see ya. . . . (walks out)

Illustration Two (Summarization of Quick Multiple Client Disclosure)

CLIENT: I don’t even know where to start. What a week! First, my car
broke down—my fault, too. I changed the oil and somehow didn’t get the
176 CHAPTER SIX

filter back on right, and it leaked and then I blew up the engine. God, I’m
an idiot. My wife has even told me before—just take the damn car to the
shop—why are you wasting your time on it. And I was trying to save
money! Well, so much for that! We’re talking a thousand-dollar oil change
now. I haven’t even told her yet that the damn thing blew up. I can’t
stand the argument out of that one. Things aren’t exactly great between
us and this isn’t gonna help. You know how she gripes about money all
the time. Which, come to think of it, is why I wanted to do the oil change
myself to begin with. I thought she’d be pleased. Oh man, there is just no
pleasing her, though. I don’t know why I keep trying. Maybe if I work
some overtime this month I could get the repairs done without even
telling her. What do you think? But then again you know how things are
with construction in the winter. There may be no overtime to be had.
Plus my boss isn’t so pleased with me because I was late again three times
this week. Like I said—the week from hell. Why was I late? Yeah, I can
read your mind-—well, I partied a little too hard with Joe. He got divorced
last week. Did I tell you that already? They’ve been separated for a year
or so and the paperwork finally got done, so he was in a good mood. He
was buying so I went along. You know me—I’m always ready for a party.
Met some nice gals, too . . . nicer than the wife. Maybe I shouldn’t be
telling you this. Man, I feel out of control. . . . And then . . . (clinician in¬
terrupts; client is startled)
CLINICIAN: (decides to interrupt as client is becoming increasingly agi¬
tated) Wow, it was a loaded week! (paraphrase) No wonder you feel out
of control. (restatement) Let me see if I got everything. . . . Sounded like
the first thing that happened was that you and Ally were fighting about
money again and one thing you tried to do was save some money by
working on your car yourself, right? (paraphrase)
CLIENT: Yeah—I guess that’s how it all started. . . .
CLINICIAN: Then the car blew up because of a mistake you made chang¬
ing the oil, and you’re worried about telling Ally because the repairs will
cost a lot... ? (paraphrase)
CLIENT: You got it!
CLINICIAN: Then you thought of a solution, thought about working extra
hours to pay for repairs, but realized you haven’t exactly pleased your boss
recently, so the chances of getting any overtime this month are slim. . . .
(;paraphrase and restatement)
CLIENT: (nodding)
CLINICIAN: The reason your boss isn’t favorably inclined is because
you’ve been late for work because of partying a bit too freely, and this
is also a problem with Ally because you are feeling attracted to other
women, right? (paraphrase bordering on reflection of affect and under¬
lying message)
 RESPONSE TYPES 177

CLIENT: Yup.
CLINICIAN: Sounds like it all starts and ends with Ally somehow. You are
fighting about money and you are hiding news from her. In the mean¬
time, you are also tempted by other relationships. (reflection of affect and
underlying message) Does this seem like a good place to start? You know,
by looking at whats happening with you and Ally?
CLIENT: Probably. You know, if she was just more reasonable about
money the whole thing wouldn’t have happened. . . .
CLINICIAN: The whole thing? (repetition encourager)
CLIENT: Yeah—you know. The car wouldn’t have blown up, and I
wouldn’t have felt so mad at Ally when I was out partying that I kissed
that woman. (blushes, looks up startled) Oops—I let that one slip. . . .
(iembarrassed now)
clinician: So tilings went a little farther than just meeting some other
women? (nwving beyond summarization now)
CLIENT: I guess SOOOO. . . .
CLINICIAN: Wanna tell me? (phrase encourager)
CLIENT: Well! Joe and I. . . (Session goes on from there.)

These summarizations show that the clinician draws on all the other re¬
sponse types in making a summary of either a session or a topic area. They also
serve to show how the clinician works with the client by double-checking in¬
formation and getting affirmation that the counselor is on the right track or that
the client agrees with the clinician’s understanding of the situation. In both
cases, the summarization clarified for both client and clinician where they were
or had been in the session. Both affects and contents were restated, paraphrased
or reflected to make sure that client and clinician were on the same page. In
both cases, summarization was a way to slow down, either to close a session or
to organize thoughts sufficiently to know where to take the session. Summa¬
rization as a means of slowing down racing thoughts and pressured speech can
be quite effective. Allowing clients to ramble with no clear goal or direction
generally will only lead them to feel confused. In this case illustration, the
client even indicated feeling out of control. Such a statement is an invitation for
the clinician to intervene and help organize the flow of thoughts.

A Few Final Comments

This chapter outlined several important response types that clinicians have at
their disposal, namely, encouragers, restatements, paraphrases, and summariza¬
tion, to ensure that clients

• feel heard
• feel listened to
178 CHAPTER SIX

Skill Development Recommendations

Recommendation 6-5 Practice the response styles presented in this chapter

with a group of peers. It is best to work in a group of four, distributing and
taking turns with the following roles: a mock client, a mock clinician, an ob¬
server of nonverbals, and an observer of verbals. The mock client will role-
play a concern presented by a therapy client; the mock clinician will attempt
to keep the client talking by using encouragers, restatements, paraphrases,
and reflections. Keep the interaction going for about ten minutes. Then stop
and give each other feedback about skills with regard to responding. The ver¬
bal observer will focus on that realm of interaction; the nonverbal-expression
observer will give more detailed feedback about that aspect of the interaction.
Discuss and observe how the appropriate use of these strategies facilitates
disclosure. Keep feedback to each other constructive and positive at this time.

• feel understood
• continue to talk freely
• continue to self-explore
• feel comfortable self-disclosing

These response styles are structured and applied in such a way that coun¬
selors communicate to their clients that they, as clinicians

• listen attentively
• listen without bias or judgment
• attend to and recognize nonverbal messages
• understand the essence of the client s statements
• understand the feeling tone of the clients communication
« are interested in hearing more
• care about the client
• want to keep the client safe

The most natural way to apply the various response types presented in this
chapter is to mix and match them. It is rare that a clinician will rely on one form
of encouraging communication or expression of understanding. Instead, clini¬
cians with experience will not only use all of these response types in the course
of a session but may also ink and match approaches within a single statement
(as was demonstrated in some of the illustrations above). In fact, it is less im¬
portant to differentiate clearly whether a statement by a counselor was an en-
courager versus a restatement, or a paraphrase versus a reflection than to have
 RESPONSE TYPES 179

mastered the execution of all of these ways of feeding back understanding to

the client. Often clinicians develop their own style of using these important
feedback mechanisms, and each counselors style may result in a unique way of
mixing the various strategies. The main thrust in using these techniques is to
remember that the work is about encouraging the client to continue to talk,
self-explore, and disclose and about helping the client feel heard, and under¬
stood. If that task is accomplished, it is quite unimportant to define clearly
whether it was an encourager or a restatement that did the trick.
 CHAPTER

Moving Beyond
Simple Communication

The Process of Empathy

No matter what role we play in life, empathy remains

the primary tool by which we come to understand and
communicate effectively with others.
C. E. Rowe and D. S. Maclsaac, 1986, p. 21

Empathy is a therapeutic skill that is difficult to achieve and yet is vital to the
counseling process. Empathy requires the sophisticated application of all basic-
communication skills, as well as a fair amount of insight, in order to help the cli¬
ent achieve the fullest awareness and healing. It can be looked at as a bridge be¬
tween skills that help facilitate communication and client self-disclosure, and
skills that are oriented toward change and growth (both affective and cognitive).
Empathy is affectively tinged with regard to clients’ experience and clinicians’
and clients language. Empathy is difficult to achieve by the clinician without a
combination of affective, cognitive, and behavioral awareness and understand¬
ing of the client.
Researchers have long looked at empathy as a composite skill with affective,
cognitive, and interpersonal components. For example, Davis (1983) concep¬
tualized empathy as a construct consisting of at least four components: per¬
spective-taking, empathic concern, fantasy, and personal distress. Perspective¬
taking is the “tendency to adopt the psychological point of view of others”
(Davis, 1983, p. 174), and is based on nonegocentric thought, requiring a more
advanced level of cognitive and social development. Empathic concern is de¬
fined as the “level of other-oriented feelings of sympathy and concern for un¬
fortunate others” (Davis, 1983, p. 174). It is based upon and reflects emotional
responsiveness and sensitivity, traits that tend to translate into altruistic help¬
ing behavior (Bateson, Duncan, Ackerman, Buckley, and Birch, 1981; Coke,
Bateson, and McDavis, 1978; Krebs, 1975; Mehrabien and Epstein,’ 1971)!
Fantasy lefers to the tendency to transpose oneself into the feelings and ac¬
tions of fictitious characters in books, movies, and plays” (Davis, 1983, p. 174),
another affective aspect of empathy that is less altruistic and more egocentric
180
 MOVING BEYOND SIMPLE COMMUNICATION 181

or self-focused. Personal distress reflects the level of “self-oriented feelings of

personal anxiety and unease in intense interpersonal settings” (Davis, 1983,
p. 174), and combines an affective and cognitive approach to empathy that is
egocentric in nature. It usually results in anxiety and personal distress, thus be¬
ing inversely related to the ability to cope effectively and possibly interfering
with positive client-clinician relationships.
Successful clinicians will have high levels of perspective-taking and em-
pathic concern, along with low levels of personal distress. Their fantasy may get
in the way if the client is perceived like a character with whom the clinician
(over-) identifies. Fantasy may be irrelevant in most cases if the client is recog¬
nized and related to as a real human being, separate from the self. Clinicians’
ability to take perspective hinges upon their cognitive ability to understand the
client accurately; empathic concern hinges upon their ability to develop a car¬
ing and compassionate relationship with clients. Clinicians’ ability to keep per¬
sonal distress to a minimum requires self-awareness and personal psychologi¬
cal health, that is, presence of the positive traits and absence of the negative
traits of mental-health-care providers discussed in Chapter One.
Given these aspects or components of empathy, one question that arises is
whether empathy can be learned or is a preexisting trait that merely needs to
be honed. It would appear that perhaps the most accurate answer is “both.”
Empathy is a trait and a skill. Empathy as a trait is the preexisting ability to take
perspective, to care for and be concerned about others, to identify with others,
and to keep personal distress to a minimum when being confronted with other
people’s plight. However, these traits need to express themselves in a manner
that is therapeutic to be useful in counseling and therapy. In other words, be¬
ing empathic (that is, having the trait) does not necessarily translate into be¬
having empathically (that is, using the skill). As Kohut (1984) points out, em¬
pathy as a trait implies that the clinician can correctly (and perhaps somewhat
intuitively) understand (empathic concern) and explain (perspective-taking)
the client’s affects, feelings, and behaviors. However, this understanding and
insight can be used positively or negatively. Truly understanding another hu¬
man being can be used negatively if that knowledge is used to manipulate the
other person. Truly understanding another person turns into empathic skill
when used to help die person grow and improve. The remainder of this chap¬
ter will focus on how to maximize the potential of empathic traits by translat¬
ing them into empathic skills.

Empathy-Preliminary Issues

Empathy as a therapeutic skill is a highly sophisticated therapeutic technique,

and yet is one of the most basic skills mental-health-care providers need to
master since it permeates almost all therapeutic work. There is little argument
182 CHAPTER SEVEN

among therapists and counselors of almost all schools of thought that empathy is
an essential therapy ingredient. These discussions rarely differentiate between
empathy as a trait and empathic skillfulness. It is likely that theorists generally
think of both trait and skill when writing or talking about empathy in a generic
sense. Although most often associated with Carl Rogers and humanist psychol¬
ogy, empathy has been addressed and researched by many other theorists (for
example, Barrett-Lennard, 1981; Brems, 1989; Davis, 1983; Kohut, 1984; Wolf,
1988). Empathy is perceived as a cornerstone of counseling and therapy by be-
haviorists, existentialists, systems theorists, psychoanalysts, and many other
thinkers. Contrary to many students’ intuitive beliefs about empathy, some of
the most empathic therapists identified through research investigations have
actually been behavioral therapists (Ivey Ivey, and Simek-Morgan, 1997).
Empathy as a trait and empathy as a skill require much of the clinician.
They are based on a number of building blocks that need to be in place before
empathy can be used successfully or at least optimally as a therapeutic skill by
a mental-health-care provider. Some of the traits and skills that are prerequi¬
site for empathic skillfulness are listed below. It is useful to note that empathy
as a trait is a prerequisite for empathy as a skill. In other words, a clinician who
does not have empathic concern, the ability to take perspective, the ability to
keep personal distress to a minimum, and the recognition of clients as human
beings with whom the clinician must not overidentify, will also not be able to
respond empathically to a client in treatment. More than likely the list of pre¬
requisite skills and traits is inadequate; there are probably many other ingredi¬
ents that enter the empathic interaction that have not yet been formulated and
studied.

Prerequisite Traits and Skills for Optimal Empathic Skillfulness

• empathic concern
• perspective-taking
• absence of overidentification
• low levels of personal distress
• acceptance
• respect
• interpersonal warmth
• genuineness
• congruence
• affirmation skills
• capacity to immerse oneself in another’s experience without getting
caught up in it
• self-awareness regarding possible countertransferences
• rapport-building skills
• communication-facilitating skills
 MOVING BEYOND SIMPLE COMMUNICATION 183

• ability to understand nonverbal communication

• ability to communicate understanding to clients
• cognitive flexibility
• creativity
• ability to recognize good therapeutic timing
• ability to conceptualize clients’ thoughts, affects, and behaviors
• ability to delay insight work

This list will probably resonate with careful readers, who recognize that
many of these traits and skills have already been addressed in prior chapters of
this text. The ones that have not been dealt with, namely, the last two skills
listed, will be addressed in further detail in the chapters dealing with cogni¬
tively oriented interventions. The list also shows, as indicated above, that em¬
pathy as a trait is a prerequisite for empathy as a skill. To keep the differentia¬
tion clear, from here on empathy as a trait will be referred to as trait empathy,
and empathy as a skill will be referred to as empathic skillfulness. Whenever
the label “empathy” is used by itself, it is employed to reflect the failure to dif¬
ferentiate in existing clinical literature.
Trait empathy needs to be differentiated from similar affective states. Spe¬
cifically, trait empathy may be confused with sympathy, identification, intuition,
co-experience, and so on. Trait empathy reflects caring, clarifies themes, stimu¬
lates self-discovery, communicates safety, and provides proof of the expertise
of the therapist (Patterson and Welfel, 1993). It helps the client become self-
aware and encourages exploration on a deeper emotional level. This is very un¬
like sympathy, which tends to be designed to squelch feelings by expressing
support and the wish for the receiver to get over her or his expressed emotion
(Meier and Davis, 1997). Empathy also must be differentiated from the notion
that therapists somehow magically intuit their clients’ experiences, get caught
up in their clients’ emotion, provide approval or advice, or attempt to under¬
stand how they might feel in the same situation (Rowe and Maclsaac, 1986;
Wolf, 1988). Table 7-1 identifies how such traits differ by defining them and
pointing out their differences.

Empathic Skillfulness as a Cyclical Process

Empathy, as originally defined by Rogers and expanded upon by modern writ¬

ers, is the ability to understand the affective experience of others from their
perspective. It presumes acceptance of the client, though it does not imply ac¬
ceptance of a client’s specific behavior. Empathy is not used to excuse un¬
acceptable or dangerous behavior, but merely accepts clients and their need to
engage in a given behavior (Ivey, Ivey, and Simek-Morgan, 1997). Empathy
thus defined most closely resembles trait empathy. Empathy has also been
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186 CHAPTER SEVEN

conceptualized as a process (Barrett-Lennard, 1981), and in that definition

most closely resembles empathic skillfulness. This empathic process has been
described as cyclical and consisting of multiple phases or stages (for example,
Brems, 1989, 1999; Egan, 1994; Patterson and Welfel, 1993). The cyclical pro¬
cess of empathic skillfulness as defined here has five stages or phases. It begins
with Phase One, self-expression by the client (Brems, 1999), and Phase Two,
the reception or perception of the client’s expressed message. It continues with
Phase Three, the clinician’s ability to understand and process the message ac¬
curately (as affected by theoretical orientation), leading to Phase Four, the cli¬
nician’s assertiveness to feed the essence of the message back to the client
(Egan, 1994). The cycle closes when the client hears the feedback and feels un¬
derstood and acknowledged (Phase Five). If the cycle closes successfully, the
client will be motivated to self-express once again, reinitiating the cycle.

The Phases of the Cycle of Empathic Skillfulness

Figure 7-1 provides a visual representation of this empathic process. The cycli¬
cal or process definition of empathic skillfulness sounds somewhat reminiscent
of the definition provided earlier for the process of reflection. There is a criti¬
cal difference, however. A reflection is merely designed to keep the client ex¬
ploring and talking; an empathic response (although often sounding like a
reflection and being structured like a reflection) is designed to enhance the cli¬
ent’s self-awareness and to express understanding of the client by the therapist.
The statement made in the course of the empathic process is additive; a reflec¬
tive statement accurately captures the client’s expression without adding (or
subtracting) information. This issue of the additive nature of the empathic re¬
sponse will be discussed further below. The phases of empathic skillfulness uti¬
lize many of the basic communication skills that have been discussed in the
context of facilitating client self-disclosure. It is in the context of empathic skill¬
fulness that these basic therapeutic skills truly come to life and are used to their
fullest potential. Table 7-2 outlines the essential skills and traits that facilitate
each phase of the cycle of empathic skillfulness.

Phase One: Client Expression

Each and every cycle of empathic skillfulness begins with a client disclosure.
Much of this text has dealt with how to facilitate self-disclosure. All of the com¬
munication skills covered so far (for example, restatements, paraphrases, en-
couragers, and reflections) serve to help the client share with the clinician
those topics that are of importance and concern to the client. Clinicians must
not forget that client self-expression is both verbal and nonverbal. Paying at¬
tention to what the client does in the therapy or counseling room is as impor¬
tant as hearing what the client says. Facilitating client self-disclosure is not only
a generic therapeutic task, but also the necessary first ingredient to initiate the
 MOVING BEYOND SIMPLE COMMUNICATION 187

Phase Five Phase Two

Clients hear the Clinicians accurately
clinician’s message and receive clients’ verbal
feel understood, affirmed, and nonverbal
and acknowledged messages
A

Phase Four Phase Three

Clinicians feed back their Clinicians understand
understanding to the clients’ messages
clients in an experience- and make sense of them
near manner that can according to their
be processed by the client theoretical orientation

FIGURE 7-1
The Five-Phase Cycle of Empathic Skillfullness.

cycle of empathic skillfulness. Clinicians who talk too much, are judgmental,
have prejudices, or subscribe to stereotypes will not encourage or motivate cli¬
ents to talk. Not surprisingly, these are the very clinicians who are generally not
perceived as empathic by their clients and their supervisors.

Phase Two: Clinician Reception

The reception or perception aspect of empathy is greatly dependent upon the
therapists ability to hear, see, and sense what the client is attempting to com¬
municate. It also is dependent upon a counselors ability to sift through a large
set of data to find the essential component or message. The perception of the
clinician needs to be unclouded by preconceived notions, and all the cautions
provided about the reception process in the chapter about attending skills ap¬
ply here as well. For example, evaluative, inadequate, filtered, selective, or fact-
centered listening in one way or another prevents the clinician from accurately
hearing the client. Rehearsing while listening, or getting caught up in the affec¬
tive content of the client s communication, equally get in the way of receiving the
 188 CHAPTER SEVEN

TABLE Essential Traits and Skills That Facilitate the Various

7-2 Phases in the Cycle of Empathic Skillfulness
_

Facilitating Trait or Skill of the

Phase in the Cycle Clinician

One: • Facilitation of self-disclosure/client verbalization

Client • Attending skills for client verbal communication
Expression • Attending skills for client nonverbal communication
• Use of basic communication skills (e.g., encouragers, paraphrases)
• Awareness of how personal clinician variables may influence client
disclosure

Two: • Physiological functionality and acuity of necessary clinician senses

Clinician • Good active-listening skills
Reception • Avoidance of listening errors
• Freedom from or awareness of effects of personal biases, stereotypes,
beliefs, prejudices, and expectations
• Self-awareness regarding how clinician's personal beliefs can influence
hearing accuracy
• Personal mental and physical health (to reduce distraction)
Three: • Ability to make sense of client information according to a theoretical sys¬
Clinician tem that explains human behavior
Understanding • Creation of a larger context for understanding the client (e.g., cultural
variables, socioeconomic, religious/spiritual variables)
• Vast store of knowledge about the client’s past and current circum¬
stances, belief systems, experiences, and values
Four: • Adaptation of verbalization to client’s cognitive abilities and preferences
Clinician • Avoidance of jargon
Expression • Expression of warmth, caring, and comfort
• Assurance of client’s sensed embeddedness in a caring holding
environment
• Experience-near expression of understanding
• Avoidance of experience-distant verbalizations
• Emphasis on understanding, not explanation
Five: • Assessment of the physiological functionality and acuity of client’s
Client necessary senses
Reception • Facilitation and establishment of the client’s attention
• heightening of the client’s interest in what the clinician has to say
• Timing to support creation of sufficient rapport
• Matching of client language

clients message. On the other hand, the active listening skills (see Table 4-6)
serve to enhance the clinicians reception.
Beyond being psychologically and emotionally ready to hear the client ac¬
curately, reception is also dependent upon the physical readiness of the clini¬
cian to hear the client. Clinicians who have hearing impairments need to be re¬
sponsible enough to wear hearing aids or take other necessary measures to make
suie they can literally hear what the client is saying. Similarly, if a clinician did
not understand something the client said, perhaps due to distractedness or due
to a clients low voice, it is important to ask the client to repeat what was said.
 MOVING BEYOND SIMPLE COMMUNICATION 189

Language differences need to be considered as well. If client and clinician have

different native languages, misunderstandings are possible and can derail the
reception phase of the empathic process, leaving the cycle incomplete or inac¬
curate. Clarifying meanings when in doubt is also crucial.
Reception of the client’s expression in the context of empathic skillfulness
goes beyond the accurate perception and hearing of the client, however. It also
includes what Kohut (1977) called prolonged empathic immersion in a clients
experience. This immersion refers to the clinician’s ability to focus consistently
on the experience of the client without clouding that experience with personal
reactions or countertransferences. This ability requires that clinicians be self-
aware and recognize how their biases, beliefs, values, stereotypes, and expec¬
tations may influence their reception of information. Clinicians need to be
aware that they may mishear clients if they have preconceived notions about
what the client is going to say or how the client may feel. Although client-focus
implies diat the clinician can recognize what the client experiences, it does not
imply that the clinician identifies with the client and gets caught up in the ex¬
perience. Instead, it implies that mental-health-care providers recognize the
depth and intensity of the “moment-to-moment experiences of the [client] but
also the continuous flow of these experiences over time. Kohut refers to the at-
tunement to this continuous flow of moment-to-moment experiences as pro¬
longed immersion or as long-term empathic immersion in the psychological
field” of the client (Rowe and Maclsaac, 1986, p. 18). Sympathy or overidenti¬
fication are successfully avoided, leaving the counselor open to perceive the ac¬
tual experience of the client. Awareness of the client’s current experience and
its relationship to past experience will help the clinician reach the next phase
of the empathic skillfulness cycle, namely, that of correctly understanding the
client’s experience.

Phase Three: Clinician Understanding

Once the reception phase is mastered successfully and the clinician has accu¬
rately (physically and psychologically) received the client’s message, it is neces¬
sary to process the information in the context of the clients overall history. This
processing is not done out loud, but rather takes place (often in the fraction of
a second) in the clinician’s head. The processing or understanding phase of the
empathic cycle requires that the therapist make sense of the client’s communi¬
cations. This aspect of empathy is most susceptible to the therapist’s theoretical
preferences (Patterson and Welfel, 1993). The affects, thoughts, and behaviors
expressed by the client will be understood slightly differently depending on
school of thought; cognitive-behaviorists will look for cognitive distortions, irra¬
tional beliefs, and automatic thoughts that have been reinforced and developed
over a lifetime; humanists will look for evidence that the client is nonauthentic
in her or his self-expression, lacking in genuineness and congruence, and will
seek to understand how these realities came about; and self-psychological
190 CHAPTER SEVEN

psychodynamicists may look for expressions of specific needs and how their
failure to have been met in childhood has affected current relationships and
self-perceptions.
It is this phase of the empathic-skillfulness cycle that most closely resembles
Kohut’s (1982,1984) definition of empathy as vicarious introspection. As noted
above, one aspect of empathy, according to self psychologists, is the prolonged
immersion in the clients experience, without getting caught up in it, for the
purpose of better understanding clients from their unique perspective. It in¬
volves a process of data collection (Phases One and Two) that leads to under¬
standing of the client (Phase Three) (Wolf, 1988) while using the therapists own
affective experience with and reaction to the client as a guide (Mahrer, Boulet,
and Fairweather, 1994). The aspect of empathy that is expressed in Phase Three
of the empathic-skillfulness cycle is a tool for gaining an understanding of the
client that will be used in later phases to help the client gain self-awareness and
a sense of being accepted and understood (Kohut, 1982,1984). Kohut referred
to this aspect of empathy (or this phase in the empathic process) as vicarious
introspection, emphasizing that this process is a critical element not only in the
therapy relationship but also during healthy development. Vicarious introspec¬
tion helps the clinician know how the client feels in a given situation because
of an appreciation of the client s developmental history, relationship history, and
larger life context. Parents use vicarious introspection to understand their chil¬
dren; it is a way to gain an appreciation of the other persons experience based
on die knowledge about that persons life. Vicarious introspection is useful for
parents in knowing how their children feel or predicting how they will react
based on their joint experience in life together. Kohut postulated that it is the
breakdown in understanding between caretaker and child that is the precursor
to psychopathology and hindered development as it makes it impossible for the
child to internalize a healthy, cohesive, strong, and orderly self (Kohut and Wolf,
1978; Kohut, 1984). Similarly, clinicians learn to recognize a client’s experience
or to predict a clients reaction through their joint exploration of the client’s life.
Therapeutic rapport ruptures (Phase Three of the empathic skillfulness cycle
fails) when the mental-health-care provider fails in the attempt to introspect
vicariously, that is, when the clinician misunderstands the meaning and nature
of the clients experience.
To summarize, understanding, as practiced in Phase Three, considers cli¬
ents’ developmental history, family circumstances, cultural embeddedness,
and interpersonal values to make sense of a given self-disclosure or communi¬
cation. The clinician in Phase Three does not merely grasp the emotional flavor
of clients messages, but understands (explains) them in terms of current lev¬
els of functioning, expressed and unexpressed needs, interpersonal adjust¬
ment, level of self development, and life circumstances (both past and pres¬
ent). The prerequisites for Phase Three are cognitive in nature. The clinician
must possess the cognitive skills to make sense of how the client reacts, feels,
 MOVING BEYOND SIMPLE COMMUNICATION 191

thinks, and behaves given the client’s life context. These cognitive skills of gain¬
ing understanding and forming explanations will be dealt with in the chapter
on advanced cognitive skills.

Phase Four: Clinician Expression (or Feedback)

Regardless of the specific content of the understanding gleaned by the therapist
(that is, regardless of theoretical orientation), the next phase of the empathic
response involves the expression of that understanding in a genuine and warm
manner to the client. This response will have a cognitive and an affective com¬
ponent. The cognitive component of the response will have slightly different
contents depending on how the mental-health-care provider chooses to derive
meaning (that is, according to the clinicians school of thought). However, the
affective component of the empathic response is the same across all schools of
thought: The communication must be genuine, warm, respectful, and useful to
the client. A response that is cliche, gives advice, parrots, or gives sympathy
represents an empathic failure (Egan, 1994). Feedback may involve merely ex¬
pressing understanding and acceptance of an expressed affect or may involve an
experience-near interpretation along with the communication of understand¬
ing. Phase Four does not consist just of an explanation; it always involves under¬
standing and caring as well (that is what makes it empathic, after all). In other
words, in Phase Four understanding is always a necessary ingredient (Strauss,
1996); interpretation or explanation are optional additions, used only in the
empathic-sldllfulness cycle if they can be delivered in a caring and experience-
near manner. The difference between understanding and explanation and be¬
tween experience-nearness and experience-distance is explained further in the
chapter on advanced cognitive interventions.
How clinicians express their understanding of the client is determined not
only by their awareness of and insight about a given client’s experience, but also
by a number of other client factors, such as client cognitive level and complex¬
ity, as well as language skills and preferences. For example, the client’s cogni¬
tive level of processing must not be exceeded lest the clinician’s verbalizations
make no sense to the client. Adapting clinician verbalizations to the client’s
abilities and preferences requires paying attention to issues such as

. using the client’s native language whenever possible

• using a volume sufficient to be heard
• using the same phrases and vocabulary as the client does (as appropriate;
for example, racist language would be avoided even if used by the client)
. adapting to the client’s preferred modality (for example, using visual,
auditory, or tactile language)
• avoiding jargon
. using simple phrases and easy-to-understand vocabulary
• keeping statements brief and nontechnical
192 CHAPTER SEVEN

Expression also requires a psychological component that communicates

warmth and caring for the client. Often just the content of the clinicians ex¬
pression in and of itself is comforting and acknowledging, and perceived as car¬
ing by the client. However, not all clients can appreciate the content alone.
Phase-Four verbalizations will be accepted by the client more easily and will be
more useful to the client if delivered with emotional caring and warmth. Com¬
municating empathic acceptance and caring to the client when expressing an
understanding requires that clinicians consider the following factors in choos¬
ing their verbalizations:

• waiting for appropriate rapport

• waiting for the client to be in an emotional state that is receptive to clini¬
cian input
• using a soothing voice or a voice that matches the content to be expressed
• making appropriate eye contact
• achieving appropriate physical proximity
• being congruent in verbal and nonverbal expression
• being genuine in what is being said
• being calm and centered during delivery
• having more concern for the client s well-being than for the clinicians
need to be right
• paying careful attention to the client s nonverbal reactions while the clini¬
cian is speaking

If the clinician is successful in incorporating both cognitive and affective

congruence into the verbalization, the expression of understanding is more
likely to be received by the client. Learning to use language appropriately is
very important to the success of the empathic-skillfulness cycle.

Phase Five: Client Reception (or Feeling Understood)

The empathic-skillfulness cycle is not complete unless the client receives the
clinicians message. Reception refers to both the physical readiness and the psy¬
chological readiness of the client to perceive the clinicians expression. In other
words, the client must be able to have sufficient cognitive skill to understand
what the clinician is saying as well as having the physical ability to hear. The
same issues that were discussed with regard to the physical aspects of recep¬
tion during Phase Two apply here, with the difference being that the clinician
must now ensure that the clients physical reception needs are accommodated.
Clinicians need to know what if any hearing or perceptual impairments clients
may have that may get in the way of pure perception of the clinician’s message.
More importantly, clinicians need to have an appreciation of how the client
tends to react to different modes of expression by others. For example, if the
clinician knows that the client tends to shut down and ignore messages if they
 MOVING BEYOND SIMPLE COMMUNICATION 193

are delivered in a stern or authoritarian manner, then such delivery would be

avoided. Some clients may only pay attention if a message is delivered with au¬
thority and confidence, whereas others listen more if a message is disguised in
guiding questions. Learning what induces a client to pay attention and to give
credence to a verbalization helps the clinician make choices and adaptations in
the delivery of a message that optimize client reception.
Most clients have language preferences that help them hear or understand
others better if they are matched. For example, some clients may use kines¬
thetic language (phrases or words such as “I feel. . .,” “I sense . . . ,” “my intu¬
ition . . . ,” “there is a sense that. . .”)• Another client may use visual language
(phrases and words such as “I see this clearly now...,” “I’m having trouble get¬
ting a picture of. . . ” “in my minds eye . . .”), whereas yet another individual
may prefer auditory language (phrases and words such as “what I’m hearing
“that sounds like ...,” “to my ears that’s ...”). Other clients may choose thought-
based vocabulary (including phrases and words such as “I’m thinking ...” “I
just know . . . ,” “what I think is happening . . .”) or affect-based vocabulary (“I
feel that...” “it really touched me when ...” “my skin crawled when . . .”).
If clinicians can match the client s modality in expression, they increase their
likelihood of being heard by the client. On the other hand, if a clinician speaks
in a modality to which the client cannot relate, the client may not receive the
clinicians message, although the message itself was very accurate and not
threatening to the client.
Another important aspect of delivery that influences client reception is tim¬
ing. Premature expression of explanations or interpretations in Phase Four will
more likely lead to client withdrawal or defensiveness. In the early stages of ther¬
apy or counseling, it is best to limit Phase-Four verbalizations to expressions of
empathic understanding, rather than explaining. Once firm rapport and caring
has been established in the relationship, more-advanced cognitive strategies
may be embedded in Phase Four as well. However, if these interventions are
used prematurely, they are very likely to decrease a client’s receptivity.
Clients who have successfully received the clinician’s expression of em¬
pathic concern and perspective will feel understood, affirmed, and acknowl¬
edged. They will feel profoundly cared for by the clinician who will be perceived
as being in tune with the client. Such experiences of being truly heard and ac¬
curately understood are rare for many clients in their lives outside of treatment.
It is for this reason that empathic skillfulness in and of itself can have “curative”
effects. Although there is some debate whether empathy alone suffices to help
clients change and grow, there is little argument that empathic skillfulness “may
serve a secondary therapeutic function in that it can establish a meaningful
supportive bond between” client and mental-health-care provider (Rowe and
Maclsaac, 1986, p. 21). If nothing else, client reception of an empathically skill¬
ful verbalization by a counselor will motivate the client to self-disclose further.
 194 CHAPTER SEVEN

It will stimulate clients to want to share more of themselves with their clinician
and as such is a powerful force in keeping therapy moving and in helping cli¬
ents explore their lives in increasing depth (Kohut, 1984). Thus, not surpris¬
ingly, closure of one empathic-skillfulness cycle often leads directly to the ini¬
tiation of another (as shown in Figure 7-1).

Sample Transcript of a Cycle of Empathic Skillfulness

Empathic skillfulness affirms, acknowledges, and validates clients, their af¬
fects, needs, thoughts, conflicts, relational patterns, and behaviors in a manner
that considers the here-and-now, without excusing behaviors or justifying them
if they are dangerous or inappropriate (Teyber, 1997). Empathic skillfulness
has as its essence “understanding [that] connotes warmth and a feeling of con¬
cern for clients” (Teyber, 1997, p. 41) and is the prerequisite for the creation of
a therapeutic holding environment wherein the clinician contains clients’ dis¬
tress and need states. Empathy and empathic skillfulness are essential for at¬
tachment to occur and, hence, are helpful or perhaps even needed for the es¬
tablishment of a working alliance that helps clients become motivated for
treatment and ongoing self-disclosure. In essence, empathy and empathic skill¬
fulness become the cornerstone of therapy, primary tools through which cli¬
nicians come to understand their clients and communicate effectively with
them. They are tools without which the process of psychotherapy and counsel¬
ing may be doomed to failure much as their absence during the developmen¬
tal phase interferes with healthy self development (Rowe and Maclsaac, 1986;
Wolf, 1988). An annotated example of an empathically skillful communication
cycle in a clients sixth session follows.

Phase One: Client Expression

The client expresses a concern about being able to tell the clinician about
a i ecent sexual encounter. This has happened before and the clinician has
let it go, not wanting to push the client into premature self-disclosure.

CLIENT; I don’t really want to talk about it. It’s not something I want you
to know because I don’t want to have to discuss the details and you
wouldn’t understand anyway.

Phase Two: Clinician Reception

The clinician hears the client’s message, which is that he does not want to
tell her about his sexual encounter. However, she also hears that this is
the first time that he explains why he does not want to talk (“You wouldn’t
understand anyway"). Thus, the clinician hears the overt verbal message
saying the client does not want to talk about it, as well as the hidden mes¬
sage that he fears her judgment. The clinician is aware that the client is
making full eye contact this time, whereas on previous occasions he
 MOVING BEYOND SIMPLE COMMUNICATION 195

avoided eye contact. She concludes from this behavior that the client may
be ready to talk about the sexual encounter if she can give him reassur¬
ance about and can explore his fears about her potential judgment (or
lack of understanding) of his behavior.

Phase Three: Clinician Understanding

The clinician understands the client’s fear of her judgment because she
knows that he was raised in a critical environment, by a mother who sel¬
dom approved of her son’s behavior. The clinician understands that sexu¬
ality is the client’s way of getting close to people and that he is starved for
health y emotional con tacts because of a deprived affective environment
(both past and present). She is aware that he has an approach-avoidance
conflict regarding emotional relationships, craving them and fearing
the7n at the same time. Superficial sexual relationships are his way of get¬
ting closeness for a brief time and walking away from it when it becomes
too overwhelming for him.

Phase Four: Clinician Feedback

The clinician chooses to communicate her understanding of the client
empathically to encourage further exploration at a deeper level. Her re¬
sponse is cautious and does not add explanation despite the fact that she
has insight about the “why” of his behavior. In other words, her empathic
response chooses to address his fear of judgment (the “what”), not the
reason for it (the “why”). Moving to the “what” still moves beyond the
overt message of the client, making the clinician statement empathic (not
merely reflective). Moving beyond that understanding to an explanation
might have seemed too large of a leap and have been perceived by the cli¬
ent as experience-distant, further affirming for him that emotional con¬
tact is painful, increasing his approach-avoidance conflict about getting
close to people.

CLINICIAN: I am very touched by how worried you are that I might

judge you somehow, that I might like you less somehow because of some¬
thing you did.

Phase Five: Client Reception

The client listens intensely and is able to hear the clinician’s message. He
acknowledges feeling heard and then initiates another self-disclosure that
begins a new cycle.

CLIENT: Yes. For some reason your opinion is important to me and it

would be risky to tell you something you may not approve of. . . .

The client-clinician interaction continues as follows, going through sev¬

eral cycles of empathic skillfulness:
 196 CHAPTER SEVEN

clinician: It’s scary to tell everything about yourself, and you want to
be sure you can trust me first. That makes good sense. Is there something
I can do to show to you that I will not feel less about you because of
something you did?
CLIENT: I’m not sure. ... I guess, just listen and don’t criticize. You
know, don’t get all moral on me and tell me I shouldn’t be doing it. . . .
clinician: Just listen and keep caring about you; not judge you . . .
I can definitely do that.
CLIENT: You can?
clinician: Yes. But the important thing is that you believe that. That
you trust me enough. And that has to be your leap of faith.
CLIENT: I would like to trust you. . . .
clinician: It sure makes things a lot easier when you can trust. You can
be yourself, say what’s on your mind and you don’t have to worry so
much. It would be a relief, wouldn’t it?
CLIENT: Yes, it would. It’s so hard to hold back, you know. I just want to
spill my guts, but I get so scared. (gets a little teary)
clinician: (nods head) I know. . . . (very softly; leans forward slightly)
CLIENT: A leap of faith, huh?
clinician: (just nods and waits)
client: Okay. I can do this. . . . (long pause)
CLINICIAN: (continues the silence, empathically allowing the client tem¬
poral space to make up his mind)
CLIENT: (takes deep breath) Alright. Well, what happened is . . . (Session
continues from he re.)

This example demonstrates that empathic skillfulness is a process that of¬

ten, if not always, has its roots in a here-and-now occurrence between client
and clinician but must be understood by the clinician as of greater significance
in the context of the client’s entire life history and development. It is not a
warm fuzzy feeling (though conveyed with warmth), but an important tool that
encourages self-awareness, self-respect, and self-acceptance. Empathic skill¬
fulness, as demonstrated by this example, is possible if empathy exists as a trait
in the mental-health-care provider. Only the clinician who has the empathic ca¬
pacity to understand the client affectively and cognitively (that is, who can take
perspective and has empathic concern without letting personal distress get in
the way) will be able to use this understanding to initiate a communication cy¬
cle reflective of empathic skillfulness.
The example shows that an empathic (Phase-Four) response purely based
on understanding is different from a therapeutic explanation or interpretation.
Its purpose is not to explain, despite the fact that understanding and self-
awareness are central to its definition. The type of understanding that is referred
to in the context of empathic responding has to do with conveying the clinician’s
 MOVING BEYOND SIMPLE COMMUNICATION 197

recognition and acknowledgement of clients and their essential and powerful

emotions and needs (it is, in other words, concerned with what the client is ex¬
periencing). This is different from conveying an explanation to clients about
why these feelings and needs have emerged (this is concerned with explaining
why the client is having a particular experience). Empathic skillfulness that in¬
volves understanding (not explanation) in Phase Four is experience-near; it
conveys an important relationship component between client and clinician that
often leads clients to accept their own feelings and needs more completely. The
self-acceptance and self-awareness of needs and affects is merely that: recog¬
nition that these needs and emotions exist within the self (when prior to ther¬
apy they most likely were repressed, denied, or otherwise kept hidden from the
clients conscious recognition and acceptance). The next step, which is insight
(that is, an explanation as to why they exist), no longer uses exclusively under¬
standing, but adds explanation, focusing on insight-creating strategies.

The Additive Nature of Empathic Skillfulness

Two distinctive features of empathic skillfulness are its cyclical and additive na¬
ture. The cyclical or process nature of empathic skillfulness has been explored
so far. It is now necessary to attend to the additive nature of empathic skillful¬
ness. Unlike in a reflection, in Phase Four when clinicians express an under¬
standing of the client, they not only feed back (or reflect) what the client said
or knows, but also add an understanding that has neither been verbalized by
the client nor consciously recognized. In making an empathic (Phase-Four) re¬
sponse, the clinician provides an understanding to the client that goes beyond
what the client could have expressed or figured out alone. The additive nature
of the clinicians response is driven by the clinicians ability to understand the
clients expression in the larger life context and history of the client that has
been discussed in counseling up to date. The additive component of the clini¬
cians expression derives from an understanding of the circumstances leading
to a clients current experience. Theoretical orientation plays some role here in
what the clinician perceives as important in having shaped the clients current
experience and thus influences the content of what a clinician may add. The fact,
however, that an addition is made seems to be accepted among most mental-
health-care providers.
Several decades ago, social psychologists began exploring empathic re¬
sponses and identified the additive nature of the response as the crucial feature
that distinguished empathy from other human interactions. Carkhuff (1969)
developed a rating system for human responses and verbalizations in interper¬
sonal contexts that looked at the level of addition and attention expressed by a
response to another human being. This rating scale has become the basis for
198 CHAPTER SEVEN

looking at level of empathic expressiveness or responsiveness among clinicians

and other communication partners (for example, Brems, Fromme, and John¬
son, 1992; Hammond, Hepworth, and Smith, 1977). Hammond, Hepworth,
and Smith developed an Empathic Communication Scale that rates therapists
responsiveness or empathic skillfulness based on the level of subtraction or ad¬
dition reflected in their verbalizations. They proposed five levels of empathic
responsiveness, ranging from responses that subtract from the meaning ex¬
pressed by the client (that is, that are unempathic) to responses that signifi¬
cantly and accurately add to the meaning expressed by a client (that is, that are
empathic). Brief definitions of the five levels follow, quoted from Hammond
et al. (pp. 98-99).

Empathic Communication Scale

Level 1.0. The counselors verbal and behavioral responses are irrelevant,
subtract significantly in affect and content, and do not attend appropri¬
ately to the others expressions. The counselor communicates no aware¬
ness of even the most obvious, expressed surface feelings of the other
person. The responses include premature advice-giving, arguing, chang¬
ing the subject, criticizing, pontificating, and asking questions that shift
the focus from the expressions of the client.

Level 1.5. Counselor responses qualify as negligently accurate, and any

of the client s feelings that are not distinctly defined tend to be entirely
ignored. Counselor responses may mislead or block off the client. The
client does not go to a deeper level of self-exploration.

Level 2.0. The counselor responds to at least part of the surface feelings
of the other person, but a response noticeably subtracts affect or distorts
the level of meaning. Awareness of the clients expressed feelings is only
partially communicated. The counselor may respond to [her or] his own
conceptualizations rather than to what the client expressed. Some re¬
sponses may have diagnostic or psychodynamic accuracy, but not em¬
pathic accuracy.

Level 2.5. The counselor wants to understand and makes the effort, but
[her or] his responses subtract slightly from the level of feelings the other
expresses. Responses that merely parrot expressions of the other person
in the same words belong to this level.

Level 3.0. Responses communicate understanding at the level of feeling

the client expresses. The counselors responses are essentially inter¬
changeable, or reciprocal in affect with the surface, explicit expressions of
the other individual, or they accurately reflect [her or] his state of being.
The responses do not add affect or go below the surface feelings, nor do
they subtract from the feelings and tone expressed. Factual aspects of the
 MOVING BEYOND SIMPLE COMMUNICATION 199

clients message (content), though desirable, are not required; if in¬

cluded, content must be accurate.
When expressed feelings are vague or ill-defined, inquiries used to
expand to the expression of feeling or to explore meaning are appropri¬
ate. However, if feelings are stated explicitly or are clearly implied, then
inquiries alone, without responsiveness to the feelings, are noticeably
subtractive (Level 2.0).
Responses at Level 3.0 are minimally facilitative and helpful.

Level 3.5. The counselors responses reflect not only the feelings but also
the reasons for the feelings that the other person expresses—in other
words, the counselors responses complement feelings with content.

Level 4.0. The counselors responses accurately identify implicit, under¬

lying feelings somewhat beyond the expressions of the client and com¬
plement feelings with content that adds deeper meaning.

Level 4.5. Responses exceed Level 4.0 but fall short of Level 5.0.

Level 5.0. The counselors responses significantly add to the affect and
meaning explicitly expressed by the client. Additionally, the counselor’s
responses accurately communicate the affect, meaning, and intensity
of the other persons deeper feelings by word, voice, and intensity of
expression.*

Level One and Level Two Responses: Empathic Failure

Versus Optimal Empathic Failure
Clearly, responses that meet criteria for Levels One and Two (as well as their
sublevels) cannot be considered empathic responses. They are responses by
clinicians who are unaware of the client s true affect, unclear about the client s
message, and unable to understand the clients current (or past) experience.
These clinicians are likely to have poor rapport with clients, especially if Level
One and Level Two responses preponderate. All clinicians will, of course, make
an occasional Level One or Level Two response, as all humans are fallible. It is
only the consistent or predominating presence of responses at Levels One or
Two that suggests a problem in the therapeutic relationship that is based on
lack of empathy in the clinician. The occasional failure, on the other hand, can
even be helpful to the therapeutic process if recognized and handled correctly,
paralleling the process that takes place between a child and caretaker during
the developmental years. Occasional failure has been labeled an optimal em¬
pathic failure (Kohut, 1984; Wolf, 1988). It is an integral aspect of the process
of internalization, and has both developmental and therapeutic value. A quick

*Hammond, Improving Therapeutic Communication, 1977 John Wiley & Sons, Inc. Adopted by
permission of Jossey-Bass, Inc. a subsidiary of John Wiley & Sons, Inc.
200 CHAPTER SEVEN

overview will be provided here of internalization and how optimal empathic

failures may facilitate it; interested readers are referred to Kohut (1984), Rowe
and Maclsaac (1986), and Wolf (1988) for thorough discussions of this impor¬
tant process in counseling and therapy.
Internalization is a developmental process that begins at birth and serves
to help children develop a cohesive, orderly, and vigorous self through interac¬
tions with caretakers and significant others in their environment. Almost from
the moment of birth, children observe their environment very curiously and in¬
tently (Stern, 1985), learning much of what they will come to know during their
lifetime through imitation and modeling after significant others and through
internalizing beliefs and experiences that arise in relationships with early care¬
takers. If the environment is essentially consistent in providing for a child’s
many needs, it is considered an empathic, or properly attuned, environment.
In such an environment, caretakers correctly respond to the child with em¬
pathic interactions that reflect an understanding of the child’s needs at least at
Level Three, but usually at Level Four. Caretakers who are able to understand
their children well enough to provide for their needs have an additive under¬
standing of the child, that is, are able to respond at Level Four or Five, because
they can recognize from the context of a present occurrence what the child is
attempting to communicate. This is true even before children are fully verbal,
as is evident from the fact that parents quickly learn to respond empathically to
their infants, providing food when the child is hungry, comfort when the child
is sick, and support when the child is in need. They do all this based upon their
knowledge and understanding of the child’s environment, history, and subtle
communication. Much in the same way, a clinician learns to understand a cli¬
ent based on knowledge about that client’s personal life circumstances and
subtle nuances of verbal and nonverbal communication.
If raised in an empathic environment, that is, in an environment with care¬
takers who are capable of providing Level Four and Level Five responsiveness,
children essentially slowly become empathic with themselves, learning to ac¬
cept themselves in their strengths and weaknesses, and mastering the art of
coping with life’s challenges (though some need for affirming and strengthen¬
ing others is never completely outlived; Kohut, 1984; Wolf, 1988). The definition
of an empathic environment is not complete unless it also includes a recogni¬
tion of the reality that even the most perfectly attuned parents will occasionally
respond at Level One or Two. Personal preoccupations or needs will no doubt
enter the caretaker’s life at times in a way that interferes with the ability to re¬
spond fully empathically to the child. Although this may appear to be prob¬
lematic, parents are often relieved to learn that, if handled correctly once hind¬
sight has been achieved, this occasional empathic failure on the caretaker’s part
is an important component of a child’s healthy growth and development. The
truly empathic environment, in other words, is fortunately one that includes oc¬
casional empathic failures on the part of a child’s primary (or secondary) care-
 MOVING BEYOND SIMPLE COMMUNICATION 201

takers. This is so because it is the occasional failure of the caretaker that chal¬
lenges the child to seek strength within the self to bridge the gaps in external
empathic availability. Optimal empathic failures or frustrations challenge the
child to begin to rely on personal internalized resources to take over the affirm¬
ing or strengthening response previously provided by the caretaker.
The deciding factor about the usefulness versus harm of empathic failures
(that is, responses at Level One or Two) is essentially one of balance. Empathic
failures are optimal and allow for internalization of a healthy self if they are oc¬
casional and embedded in an overall interpersonal matrix that is adequate and
consistent at meeting or gratifying most of the child’s needs, that is, in an over¬
all and usually empathic environment. They are optimal if the caretaker (or cli¬
nician, in the case of counseling), recognizes the failure at a later time and recti¬
fies the situation, either by once again responding empathically in similar future
circumstances, or by openly admitting the shortcoming to the child (or the cli¬
ent). Nonoptimal empathic failures can take many different shapes (see Brems,
1998b; Stern, 1985). Most commonly they manifest as environments that never
meet a child’s needs. There is a preponderance of Level One and Level Two re¬
sponses to the child and a chilling absence of the kind of empathic understand¬
ing reflected in responses at Levels Four and Five. The absence of Level Four
and Five responses leads to an emotional deprivation of the child as she or he
is never fully acknowledged, affirmed, appreciated, or supported. No healthy
modeling of self-affirmation or self-strengthening has taken place; thus, when
yet another unempathic interaction takes place, the child has no cognitive (or
inner) model of strength upon which to draw when the caretaker has failed. In
such a depriving, unempathic environment the child never internalizes the ca¬
pacity for self-affirmation and self-soothing because these functions were
never provided or modeled to begin with. The same is true for the therapeutic
relationship, as will be elaborated below.
An environment also fails to be empathic if it is unrealistically overavail-
able, that is, if there are never any failures on the part of the caretakers to meet
the child’s needs for self-affirmation and strengthening. Because caretakers al¬
ways respond immediately and completely, children in such an environment
are never challenged to develop empathy within themselves and to internalize
strength to deal with difficult situations. Such children are actually the target
of optimal empathic failures as well, as the failure of the caretaker to fail (yes,
it sounds strange) deprives the child of opportunities to draw on inner re¬
sources and strengths. Such children will for the rest of their lives depend on
others to meet their needs. Healthy internalization of self-affirmation and self-
soothing depends on the overall embeddedness in an interpersonal matrix that
empathically provides for most of childrens basic needs while occasionally
leaving them to fend for themselves. It is during the occasional empathic fail¬
ures that children learn to develop skills and to begin to fend for themselves
psychologically speaking (Kohut, 1984; Rowe and Maclsaac, 1986; Wolf, 1988).
202 CHAPTER SEVEN

If it occurs in an overall empathic therapeutic relationship, the occasional

empathic failure of the clinician will fulfill the same role in a counseling setting.
Therapy and counseling, as real life and human development, rely upon the
process of internalization to help clients change. Empathic interactions with
mental-health-care providers help clients internalize adequate self-affirming
and self-soothing functions, strengthening clients in many ways without the
need for insight or explaining. Clients glean self-esteem and strength through
empathic and accepting interactions with their clinicians, much in the same way
as infants or children in healthy interpersonal environments learn to meet their
own needs by modeling after, imitating, and internalizing their parents’ re¬
sponses, values, and behaviors. This process of internalization is more or less
incidental to the work with clients as it takes place nonverbally and preverbally,
does not rely on cognitive insights, and yet builds the basis for a strong, goal-
directed and self-confident self. This type of internalization is neither encour¬
aged nor discouraged by the clinician; it happens as an incidental aspect of the
experiential nature of the therapeutic relationship. It is synonymous with simi¬
lar concepts proposed by social learning theory (Bandura, 1969; Johnson, 1994).
The internalization process that is based on the empathic rupture, or failure,
in the clinician-client relationship is an equally unplanned, yet crucial, process
between client and mental-health-care provider. As during healthy develop¬
ment, the empathic failure of the clinician is only optimal when it is occasional
and embedded in the context of a preexisting empathic relationship that has es¬
tablished an air of acceptance, genuine concern, and caring (Donner, 1991). As
stated above, it is completely unavoidable that therapists will occasionally fail
their client and will not always adequately understand and reflect their self-
expressions during counseling. Just as empathic failures in a child’s life can ei¬
ther be helpful or hurtful, empathic ruptures (that is, Level One or Two re¬
sponses) in the therapeutic relationship can be used to the client’s advantage if
they occur only occasionally, are embedded in a greater empathic context, and
are processed with the client. If clinicians were always empathic and perfectly
attuned to every need of their clients (always and infallibly delivering Level Four
and Five responses), clients would never have to learn to deal with the nega¬
tive aspects of human relationships. Clients of clinicians who never fail them
could develop the wrong impression that human relationships are about having
needs met by external sources, that is, through the constant empathic care¬
taking by others. The clients may feel better while with the clinician, but often
get worse in other relationships, where they will have the same expectations for
dependence and caretaking.
The empathic rupture in the therapeutic relationship is an imitation of the
developmental process that challenges clients to learn to soothe and care for
themselves when people fail them (or when they perceive others as failing them;
not all empathic failures are real; some are merely perceived that way by the
client). In the therapeutic relationship, clinicians, while not gratifying clients’
 MOVING BEYOND SIMPLE COMMUNICATION 203

nfeeds for affirmation and soothing (as a parent would in normal development),
usually accept and confirm the existence of given needs in their clients, by re¬
sponding at Level Four or Five to a clients verbalizations. Consistent empathic
lesponding of that nature (Levels Four and Five) helps clients recognize and
accept their needs through the therapeutic relationship. An empathic failure or
rupture occurs when clinicians happen to be unaware of an expression of need
or fail to accept it and make a Level One or Two response. In such an instance,
the client is challenged to take the role usually played by their mental-health¬
care provider: providing acceptance and understanding for an emerging need
alone and widiout their clinician’s help, at least for a while. This is the same
challenge that is met and mastered by the child during healthy development.
The empathic failure on the part of the clinician challenges clients to internal¬
ize (provide for themselves) the self-affirming and self-soothing functions that
they did not internalize during childhood (due to the unresponsive environ¬
ment provided by the caretakers at that time) and to move toward relative in¬
dependence from the counselor. This internalization ultimately leads the client
toward self-acceptance and understanding as well as enhanced self-efficacy
with regard to the clients ability to meet personal needs for self-affirmation
(mirroring) and self-soothing (idealization) (Kohut, 1984; Wolf, 1988).
To summarize, if clinicians have modeled many Level Four and Five re¬
sponses during their interactions with a given client, then when they “fail” by
making a Level One or Two response, clients will have learned to make Level
Four or Five responses for themselves. On the other hand, if all of treatment has
consisted of Level One and Level Two responses, the client will never feel val¬
ued, affirmed, and acknowledged, and therapeutic rapport will never be estab¬
lished. In that instance the therapeutic relationship recapitulates the same type
of negative relationship the client most likely encountered during childhood
and no therapeutic growth and development will be possible for the client.

Level Three Responses: Reflection Versus Empathy

Level Three responses are not yet fully empathic responses; however, they are
therapeutic responses and tend to be of value when used appropriately and in
the correct circumstances. Level Three responses are essentially reflections.
Reflections, of course, have already been discussed at length as helpful clini¬
cian verbalizations. Reflections keep clients talking by communicating that the
clinician hears what the client is saying. They do not include a deeper under¬
standing (as defined by Level Four or Five responses) that adds to the clients
communication, but merely reflect content and affect expressed by the client,
however nonverbally or hidden. On the surface, reflections may appear to add
something because the clinician uses different words than the client; however,
upon closer inspection, it becomes clear that nothing the clinician says (reflects)
has not already been expressed by the client. Clients are not usually surprised
204 CHAPTER SEVEN

by reflection responses; they already know that they have a given affect or are
expressing a particular content. The clinician merely has made overt what the
client has implied. Reflections thus perfectly fit the definition of Level Three
response as interchangeable or reciprocal.
What makes an empathic response different is its additive nature as defined
by Level Four or Five, that is, it deepens meaning and understanding to a level
previously elusive to the client. The empathic response can add or deepen mean¬
ing and understanding either by further clarifying or refining a client s under¬
standing of an expressed affect or by adding content of which the client was un¬
aware. As such, if focused on affect, an empathic response adds an underlying
affect, clarifies a coexisting affect, or highlights a shade of gray (all issues ad¬
dressed thoroughly in the chapters dealing with affect and emotion). If focused
on content, the empathic response adds meaning in the sense of an explanation
(as will be discussed thoroughly in the chapters on thoughts and cognition).
Both reflections (Level Three) and empathic responses (Levels Four and
Five) have therapeutic application. It is not always better to respond at Level
Four or Five; there are times when a reflection is more appropriate than an em¬
pathic Level Four or Five response. Reflections are indicated over Level Four
or Five responses until therapeutic rapport has been established. Making addi¬
tive comments about affect prematurely in the relationship may be over¬
whelming for a client who is not yet ready to look at affect. Similarly, making
Level Four or Five content responses prematurely can be quite threatening to
clients who are not yet ready to explore the “why” of their behaviors, thoughts,
and emotions since they have not even accepted yet that these issues manifest
as they do. The many cautions that will be discussed in later chapters about do¬
ing affective work on a level commensurate with a client s level of affective self-
awareness and expression apply in this regard. Cautions about timing of con¬
frontations, here-and-now process comments, and interpretations also are of
relevance. One aspect of demonstrating empathic skillfulness is knowing when
to use which level of empathic responding. Being capable of a Level Four or
Five response does not always mean choosing to make it. If a client is not ready
for that depth of exploration, a simple reflection may be the more therapeutic
response.

Level Four and Level Five Responses: Imposing a Viewpoint

Versus True Empathic Skillfulness
Once clients have reached a certain level of comfort with their clinician and are
beginning to search for the meaning and sources of their affects, thoughts, feel¬
ings, needs, and coping choices, Level Four and Five responses can slowly in¬
crease in frequency. These responses are theoretically fully empathic in that
they are always additive in nature. However, nothing is quite that simple. An
 MOVING BEYOND SIMPLE COMMUNICATION 205

additive response may sound like a Level Four or Five response (and even
meet the criteria quoted above), but actually be unempathic because rather
than bringing out true underlying meanings and understanding, it imposes a
clinicians viewpoint. In other words, for a Level Four or Five response to be
truly empathic, it not only has to be additive, but also accurate. The issue of ac¬
curacy of explanations and affective work is the gist of the work around self-
awareness strategies in the chapters that follow.
An additive response always draws upon a clinicians beliefs about what un¬
derlies, drives, or creates human behavior. The theoretical orientation or school
of thought espoused by mental-health-care providers will enter into their un¬
derstanding of clients’ symptom, behaviors, thoughts, affect, and relationships.
They will explain a client’s manifestations based upon how they explain human
behavior in general. The important issue that will differentiate an empathic
theory-bound explanation from an imposing one is its level of accuracy and ex¬
perience-nearness for a given client. A Level Four or Five response is empathic
if it is accurate and idiosyncratic to the client’s life circumstances, history, ex¬
periences (present and past), and subtle expressions of affect, thought, and be¬
havior. It is imposing if it ignores the client’s experience in favor of fitting the
client into a framework that is indiscriminately applied to all human beings be¬
cause of a clinician’s belief in a particular school of thought about humans. The
latter process has been referred to by Rogers as making every client a nail be¬
cause the only tool available to the clinician is a hammer. True empathy (at
Levels Four and Five) requires that the clinician possess more tools than just a
hammer and search for new tools if the existing ones do not fit a particular cli¬
ent’s presentation and experience. Each client is treated as unique, and for
each client an explanation or meaning is created that fits perfectly for that cli¬
ent and no other. When meaning is specifically and accurately tailored to the
client, additive responses become empathic and truly meet Level Four or Five
criteria.

Samples of Level One to Level Five Responses

What follows are a few brief client-clinician interactions to demonstrate re¬
sponses at various levels of the empathic-communication scale. Responses at
three possible levels are provided to demonstrate the difference between less-
than-empathic (Level One or Two), reflective (Level Three), and accurately
empathic (Level Four or Five) responses. An example of an inappropriate ad¬
ditive response is also given to help the readers gain an appreciation of the pos¬
sible negative effects of imposing viewpoints. Further, the most therapeutic re¬
sponse will be highlighted (note that the most appropriate response is not
always the one at the highest level) in a discussion of the scenario.
206 CHAPTER SEVEN

Scenario One
Over the course of five sessions, client and clinician have been discussing the
client’s attempts at looking for work. The client has been unemployed for nearly
fifteen months and has searched for work on and off during that time. Unlike
the client, the clinician has recognized that the attempts have been somewhat
half-hearted and that the client has repeatedly sabotaged his chances of actu¬
ally being chosen for position vacancies that are commensurate with his skills.
In the session from which this segment is taken, the client is just beginning to
realize his ambivalence about going back to work.

CLIENT: I guess I could have handled that slightly differently. Just start¬
ing the interview with my biggest fears about the job may not have been
too smart. . . . (truly pensive and. somewhat startled by this recognition)

Potential Clinician Responses

Level One: Unempathic Response
clinician: Yes, next time you should try to put your best foot forward
and talk about your excitement about the job instead. Employers are
more likely to hire employees who are self-assured. You certainly have
every right to be self-confident—You are a smart man. Don’t you believe
in yourself?
CLIENT: Yes, I do! But it’s hard to convince others you’re good. So many
people assume the worst, especially employers. You just can’t reason with
them. You gotta protect yourself, you know. It’s just not that easy!
clinician: Well, what can you do differently next time to make sure you
have a chance of getting hired?
client: I don’t know. That’s why I’m here.

Level Three: Reflection Response

clinician: You are realizing that you may not have made the best
choice of behavior. . . .
client: Yes. And sadly I think this is not the first time I’ve done this.
clinician: You have hurt your chances before?
client: Yes. Oh, I feel foolish. What do you think is going on?
clinician: Let’s explore that together. What are some possible reasons?
CLIENT: I didn’t feel comfortable in that environment. . . . Something
just felt off. . . .
clinician: Help me understand what you mean by “off.”
CLIENT: Well, it felt—awkward? No, that’s not quite it. I was feeling
watched or something. . . .
CLINICIAN: Scrutinized, maybe?
client: Yes! That’s it. There were five people in the room and they were
all watching me. I was scared to move and since all I felt was scared, that
 MOVING BEYOND SIMPLE COMMUNICATION 207

seemed to be the only thing I could think of to say. So I just started talk¬
ing about my fears.
clinician: What are your fears?

Level Four: Accurate Empathic Response

CLINICIAN: You are realizing that you may have been doing things that
can get in the way of actually being hired.
CLIENT: I guess so. I didn’t think of it that way, but I suppose its true.
Maybe I have . . .
clinician: Maybe you have . . . ?
CLIENT: Done things that turned employers off.
CLINICIAN: What do you suppose thats all about?
CLIENT: Maybe I’m not ready to go back to work?
CLINICIAN: You have some ambivalence about it, maybe? You’ve cer¬
tainly talked about how happy you are with taking care of Sammy and
Katie.
CLIENT: Yes, I’ve really enjoyed being home with the kids. You know,
Jennifer took a couple years off when they were little. I didn’t have that
chance. It’s been a lot of fun doing stuff with them during the day. Soon
they’ll start school and then they’ll have a life of their own, just like my
older ones. I feel like I might miss something important if I start working
again right now.
CLINICIAN: Like you might miss something?
CLIENT: Yeah. You know, with Jean and Tommie I was working through
their whole childhood years. Now don’t misunderstand. I was a very in¬
volved dad as far as time allowed. You know, I never missed a ball game,
and I was part of all their important events. But this is different. This is
so sweet. I’m there when they feel good, I’m there when they feel bad.
They check in with me. ... I have always loved being a dad and this just
is a beautiful way to spend my time. (gets teary)
CLINICIAN: You really love your children and enjoy this life. . . .
client: Yes! If I a were a woman . . .
CLINICIAN: You could just stop looking for work and no one would scru¬
tinize your decision to stay home. It would be okay. . . .
CLIENT: Exactly! (sighs)

Level Five: Viewpoint-Imposing (Unempathic) Response

CLINICIAN: It sounds to me as though you are realizing that you are re¬
ally not ready to go back to work because you have things that you need
to do in your private life first.
CLIENT: What do you mean?
CLINICIAN: You missed out on helping raise your older children. Now
you have a chance of making that up to your younger children by being
home with them before they start school in a couple of years.
208 CHAPTER SEVEN

client: I helped raise my older lads. Just because I was working doesn’t
mean I was an absent dad. I love my kids! And they don’t think I was a
bad father. (shuts down)

Discussion
In this example, the most therapeutic response was the accurate empathic
Level Four response. However, the reflection at Level Three was also appro¬
priate and helpful. The client was ready for a Level Four intervention, and it
was this readiness that made Level Four most appropriate. If the clinician is un¬
certain as to whether a client is ready to explore a deeper level, a reflection can
begin the process with careful questioning that allows for Level Four interven¬
tion if the client evidences insight and willingness to dig deeper. The imposing-
viewpoint response demonstrates clearly how inaccurate an additive response
of the clinician can be. This clinician imposed a viewpoint based in stereotypic
assumptions about family systems (and absent fathers). The assumption was in¬
correct and led the client to be defensive and to withdraw from the interaction.
The Level One response consisted of advice-giving and was somewhat critical.
The client certainly perceived the intervention as critical, which is ironic, as he
already felt scrutinized and criticized in his circumstances to begin with. Not
surprisingly, he became defensive and threatened. The clinician also never
managed to get to a true empathic understanding of the client, veering instead
in a direction that was irrelevant and counterproductive as it never helped the
client get to the point of exploring, accepting, and understanding his ambiva¬
lence. The accurate empathic response not only helped the client recognize his
ambivalence, it also facilitated an exploration of its deeper cause or meaning.
Understanding this deeper meaning helped him accept his conflicted feelings
and unearthed his true desire, which was to stay home with his young children
for now. It is likely that the reflection would ultimately have led to this recog¬
nition, acceptance, understanding, and insight. However, it would have taken
slightly longer and hence was a somewhat-less-efficient intervention.

Scenario Two
The client in this scenario has been seen for fourteen months. The clinician has
been suspecting a seasonal component to her depression, but the client has
been rejecting the notion. Instead, she tends to think that she was “doing some¬
thing wrong” and that she should be able to “just snap out of it.” In this session,
the clinician recognizes the cyclical nature of the client’s symptoms once again
and attempts to help her recognize it through empathic intervention that is de¬
signed to move her to this deeper level of understanding about her symptoms.
In the transcript that follows, various levels of responses are embedded in a
single interaction. The example shows how clinicians move from Level Four or
Five empathic responses to reflections and back, and how even occasional fail-
 MOVING BEYOND SIMPLE COMMUNICATION 209

ures do not have to interrupt the flow of treatment if they are recognized and
acknowledged, as well as embedded in an overall empathic relationship. Re¬
sponse levels are indicated in parentheses for clarification.

CLIENT: Do you realize I’ve been coming here for over a year now. And
I still feel like crap. Its pretty discouraging actually. . . .
CLINICIAN: You had hoped for more progress by now. . . . (Level 3)
CLIENT: Uh huh. (gets teary-eyed)
CLINICIAN: Feeling badly is becoming very overwhelming. . . .
(Level 3.5)
client: (weeping and nodding)
CLINICIAN: Can you tell me what you are feeling right now? (very soft
voice so as not to squelch the affect with the question) (Level 3 question
to move client to a deeper level of experience; preparing client for
Level 4 work)
CLIENT: (sobs) Hopeless . . .(weeps openly now; diverts all eye contact)
CLINICIAN: Like this will never pass . . . (Level 3)
CLIENT: (nodding softly; making some eye contact again)
CLINICIAN: This discouragement, it has happened before, hasn’t it?
(Level 4; moving client to a deeper understanding)
CLIENT: (looks puzzled)
clinician: About a month ago, I remember you started feeling the
same way; and I remember a time before that, last year in January or
February; like there is a cycle of some sort. . . (Level 4.5)
CLIENT: (looks up with interest now; tears decreasing)
CLINICIAN: Have you ever noticed anything cyclical about these feelings
before? (Level 4 question to encourage client to explore deeper contents)
CLIENT: No . . . But something just resonates . . . ’cause I was thinking
this morning, it’s so dark. ... If only the sun were back I’d feel better.
But I didn’t really think about it much. You asked me this before, didn’t
you, when I was first starting to see you. ... I dismissed it. . . . (puzzled)
clinician: What are you pondering just now? (encourager at Level 3,
reflecting recognition that client is thinking about something)
CLIENT: I didn’t pay attention. ... I never pay attention (starts to cry
again) What’s wrong with me? (sobbing now)
CLINICIAN: You are feeling so down today that everything you realize
somehow makes things worse. . . . You find a way to look at it in a nega¬
tive way. . . . (starts with Level 3 reflection and deteriorates to a Level 2
reaction that does not grasp the essence of the client’s verbalization)
CLIENT: You would too if you felt this way. (looks up; defensive)
CLINICIAN: You know, that wasn’t the best way I could have said what I
wanted to express, was it? Sorry for the way that came out. (repairs em¬
pathic rupture to turn the failure into an optimal one) What I mean is
210 CHAPTER SEVEN

Skill Development Recommendations

Recommendation 7-1 In conversations with family and friends, evaluate

in hindsight or at the time how you would feel in a given situation and com¬
pare it to how they indicate they felt. Try to understand why they feel the
way they do, based on their unique history, development, and so forth. Once
you reflect on their unique backgrounds and how they have been shaped by
them, do their reactions make more sense to you? Do you understand why
they may be reacting differently from how you or others may have responded
in the same situation?

Recommendation 7-2 Listen to the conversations of others (either strang¬

ers or friends and family members) and attempt to evaluate what you hear
in terms of the levels of empathic responsiveness. At what level of the rating
scale do most conversations appear to take place?

Recommendation 7-3 Watch a movie or read a novel, choosing from the

list below or similar products. Try to take the perspective of a lead character
to develop an empathic understanding of that individual. Does consideration
of their unique background and history assist you with developing an empathic
perspective on their lives? Does increased empathy alter your perception of
the individual? Hoiv so and why?

Movies Novels

Ordinary People One True Thing

Shoot the Moon The Accidental Tourist
Birdy The Glass Bead Game
Good Will Hunting The Fires of Troy

that some days everything looks bleak and there seems to be nothing you
can do about it—no matter how hard you try. (returns to Level 3)
CLIENT: Yes! (weeping again now) Its like this dark force takes over and
grabs hold of me. (sobs while talking)
clinician: Is there anything that you can identify that contributes to
this dark force? (encourages Level 4.5)
CLIENT: Like what?

CLINICIAN: I’m struck by you calling it a dark force_(Level 4.5)

client, (thinking) Of course. Its dark outside . . . again. I love cold
weather and snow, but I can’t stand to wake up and its dark; I go to
work its dark; I go home—it’s dark. I miss the sun. . . . (breaks into
sobs again)
 MOVING BEYOND SIMPLE COMMUNICATION 211

CLINICIAN: Its so hard to feel light when there isn’t any. . . . (Level 3.5;

approaching Level 4)
CLIENT: Exactly! Now what do I do?
clinician: You just took an important first step. (caring and soothing
voice) We tied your desperation to something deeper, something outside
of you that contributes to it. Having seasonal variations in yoiir mood is
an important thing for us to have realized—even if it doesn’t help you
feel less hopeless right now. . . . (Level 5)
CLIENT: In a strange way it does. It’s like it’s not all my fault. . . .
clinician: You’re not doing anything wrong after all. . . . (Level 4)
(Session goes from here to verbalize the diagnosis of a seasonal-affective-
disorder component to the clients affective disturbance and problem
solving.)

Discussion
This transcript clarified that an empathic response is not something that hap¬
pens once and is finished, but rather, empathic skillfulness permeates therapy
and counseling at almost all times. It moves from level to level and creates an
interpersonal relationship that is warm, caring, and supportive. Such thera¬
peutic rapport and relating has been called a holding environment. It allows
the clinician to begin to work with explanations and interpretations in a way
that is accepted by the client and perceived as caring, not intrusive. The cre¬
ation of this empathic interpersonal matrix and holding environment is an im¬
portant skill that needs to be in the clinician’s bag of techniques before moving
on to strategies that help create cognitive or affective self-awareness.
••

-
Skills for
Cognitive Awareness
in Psychotherapy
and Counseling
Working CHAPTER

with Thought
and Cognition

Overview and
Basic Skills

Man is not disturbed by things, but by his opinion

about things.
Epictetus

Once communication and empathy have been established with a client, the
therapeutic interchange can deepen to include work around issues of cognition
and affect. Over the course of counseling or therapy, clients need to recognize
their thoughts and feelings to be able to achieve true behavior change and per¬
sonal growth. There are many ways in which a clinician can assist in this pro¬
cess of self-exploration, deepening understanding, and creation of insight. In
this section of the book, focus is placed on information about and skill devel¬
opment in the area of thoughts and cognitions.
Cognitive work refers to all interventions that focus their attention on cli¬
ents' opinions, attitudes, thoughts, and cognitions. Some of this work is simple
and straightforward; some of it complex and theoretical. Given the great diver¬
sity in level of complexity and intricacy of cognitive work, clinicians need to
keep in mind the level of cognitive development of the client. Just as clinicians
need to assess clients with regard to their affective level, they need to pay at¬
tention to clients’ cognitive skills. If a client presents with a limited range of
cognitive complexity, advanced techniques of working with thought and cogni¬
tion may be beyond the reach of the clients cognitive capacity, especially if
phrased in a complicated or complex manner. Although this statement may
sound judgmental, it merely reflects a simple reality that not all human beings
function at the same level of cognitive capacity. It does not mean to imply that
some people will not benefit from counseling or therapy; it merely suggests that
they will benefit more from interventions that are tailored to their cognitive
preferences, style, and abilities.
Level of cognitive complexity is not to be confused with intelligence. Al¬
though level of intelligence can indeed be the limiting factor in a client who is
cognitively rigid and unable to think flexibly, there are emotional factors that
215
216 CHAPTER EIGHT

can contribute to this thinking style. Perhaps it is best to begin with a defini¬
tion of cognitive complexity versus rigidity. The simplest way to define and dif¬
ferentiate these two concepts is to borrow from Piagets theory of cognitive de¬
velopment. Piaget conceptualizes cognitive development as progressing from
sensorimotor thought to preoperational thought to concrete operations to for¬
mal operations, as defined in Table 8-1. Although Piaget originally conceptual¬
ized the cognitive stages of development as discrete stages, modern develop¬
mental research clearly shows that these stages are neither concrete nor discrete
at all. Human beings can function at one level of cognitive development with
regard to one type of skill, and at another level with regard to another. It is even
conceivable that they can function at one level in one context, and at another
in a different environment. Most simply put, thought that falls into the first
three categories (sensorimotor thought, preoperational thought, and, most
commonly, concrete operations) is thought that is less than cognitively com¬
plex. If evidenced by adults, it tends to be characterized by what other adults
would perceive as rigidity and inflexibility. This is in contrast to thought in the
formal operational stage of development, which has the potential for cognitive
complexity and logic. If clients evidence concrete thought or illogic and inflex¬
ibility, it is important to assess whether this pattern is pervasive, that is, char¬
acteristic of the client in all settings and contexts, or isolated. Lack of cognitive
complexity overall generally reflects a true limitation in cognitive development;
lack of cognitive complexity or flexibility in select circumstances generally
reflects an emotional or situational component that interferes with cognitive
performance in limited situations. Removal of the emotional interference or
situational circumstance often frees the client to function at a higher cognitive
level, allowing for the use of more-advanced cognitive interventions than the
clinician may have deemed possible.

A Model for Conceptualizing Working

with Thought and Cognition

The progression through Piagets stages is a normal developmental process.

Children will think in certain ways (that is, sensorimotor, preoperational, con¬
crete, formal) in a developmentally appropriate manner throughout their de¬
velopmental years. Developmental researchers have observed, however, that
somewhere around the ages of eleven to fifteen a human being should be
developing toward a level of formal operations, and after age fifteen formal
operational thought should be largely in place. Adults who seek counseling
services could theoretically be presumed to function at formal operational
thinking. Formal-operational thinking, in turn, is presumably characterized by
logic, abstracting ability, flexibility, creativity, and deductive reasoning. Most
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 217

importantly, formal operations implies that adults can think about objects,
events, and relationships without having to perceive or be in these circum¬
stances concretely at that given moment. In other words, formal operational
thinkers can take multiple perspectives without being bound by immediate
perception about die perspectives they are taking. They can recognize impli¬
cations of general principles for specific situations or relationships. Clinicians
may assume that since their clients have matured beyond age fifteen, they are
complex and logical thinkers who have these abstracting skills. Unfortunately,
as practicing clinicians can attest, this is not always the case. It is important for
clinicians to recognize that adult clients are not always functioning at the same
level of cognitive complexity in all situations and circumstances. While they
may be remarkably creative and capable of logic and abstracting ability in some
areas of their lives, in other areas they may be remarkably concrete. Interest¬
ingly, such adults may have high-level professions, college degrees, and much
formal or informal education. However, when emotionally challenged or
placed in certain situations, they revert to a level of thinking more characteris¬
tic of a child of seven to eleven than of an adult.

The Process of Normal Cognitive Development

and Implications for Therapy and Counseling
Cognitive development is viewed as proceeding through the development and
modification of schemata about the world, a process that consists of organization
and adaptation. As children mature cognitively, they begin to form schemata,
or patterns of thought about the world. As they continue to have new experi¬
ences in their environment, they modify these schemata to make room for new
impressions. One way in which this occurs is through organization, wherein the
child makes existing schemata increasingly complex, perhaps by combining var¬
ious basic schemata into one new, single overriding pattern of thought. A sec¬
ond means of modifying existing schemata is through adaptation, which in turn
can proceed through assimilation or accommodation. Adaptation of a schema
means that the child modifies the schema to adapt it to new environmental de¬
mands or uses existing schemata to make sense of new environmental demands.
Thus, whereas organization refers to an expansion or reorganization of multiple
schemata due to an integration of new learning and new experience, adaptation
refers to a revision or alteration of an existing schema or to an understanding
of a new environment based on a previously established schema. Organization
creates something new; adaptation uses something old to understand something
new or modifies something old to fit with new evidence. If adaptation proceeds
through understanding a new environmental event by an existing schema, it
reflects assimilation; if it proceeds through a revision of an existing schema, it
reflects accommodation. Assimilation can go awry if the child uses a preexist¬
ing schema for a new environmental event in a manner that is incorrect. For
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220 CHAPTER EIGHT

example, a child who grew up around large, gentle dogs may have developed a
schema that says “furry creatures are cute and cuddly.” If this child encounters
another furry creature, namely a bear, this schema can lead to problems if the
child attempts to function according to the schema “furry creatures are cute
and cuddly" and tries to cuddle up to the bear. This is an example where adap¬
tation would proceed more correctly through accommodation, which would
lead the child to modify the schema to “the furry creatures in my home are cute
and cuddly.”
The relevance of the concepts of organization, assimilation, and accom¬
modation to counseling is clear. Not only children come to therapy with certain
schemata; adults do as well. The more flexible their thinking, the more skilled
they will be in using information from the clinician to form old schemata into
new ones (organization) and to accommodate old schemata, rather than to force
assimilation where it is not appropriate (successful adaptation). Conversely, the
more rigid or inflexible their thinking, the more likely they will be to attempt
to explain new information through old schemata, forcing assimilation where
accommodation or organization would be more appropriate. Additionally, al¬
though not part of Piaget’s original thinking, cognitive development is per¬
ceived by contemporary researchers as highly influenced by the sociocultural
and emotional context in which a child matures or in which an adult currently
functions. Interactions with caretakers and other adults and peers will strongly
influence the types and styles of coping skills, problem-solving skills, and cog¬
nitive patterns or schemata children develop and employ. A child who grew up
in an environment that was deprived of successful role models or that was pre¬
dominated by role models who assimilated inappropriately will be more likely to
have stagnated at a concrete operations level of thinking, at least in some realms
of cognition. A child, on the other hand, who was challenged by role models to
integrate new learning and to take multiple perspectives on new information,
is more likely to have achieved formal operational thinking. Guidance and en¬
couragement, focused on providing sensitive instruction that fosters cognitive
growth, are critical to healthy cognitive development (Sigelman and Shaffer,
1995). These supportive behaviors are most successful if they are adapted to
the child s current level of cognitive development. In other words, the guiding
individual encourages the child to stretch beyond existing limits into new realms
of cognitive functioning. The level of encouragement needs to be such as to be
comprehensible at the child’s current cognitive level while suggesting move¬
ment to a new level of cognitive capacity. Guidance that is provided at a level
ol cognitive capacity that is beyond the grasp of the child will not be successful
as it overchallenges the child and may lead the child to give up in frustration.
Language is the primary mode through which encouragement and guid¬
ance take place. Thus, even language has to be adapted to a level that results in
understanding in the child. Adults generally spontaneously adapt their vocab¬
ulary when they interact with children, eliminating professional jargon or so-
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 221

TABLE

A Hierarchy of Cognitive Strategies and Interventions

Strategy Brief Definition Primary Purpose

Imparting Providing objective knowledge or Alter a client’s reaction or inter¬

information understanding the client did not pretation in response to a given
previously have situation
Pointing out Pointing out and tying together Help the client recognize relational
patterns multiple similar contents or patterns, core affects, or core be¬
messages given by the client liefs that have become habitual or
over time maladaptive to create the motiva¬
tion to change
Asking clarifying Planfully or purposefully question¬ Facilitate self-discovery, under¬
questions ing to lead the client to an insight standing, and insight in the client
or understanding the clinician
already has
Confrontation Pointing out inconsistencies, dis¬ Help the client recognize incon¬
crepancies, and mixed messages gruence and help the client in¬
in the client’s communication crease awareness and a new way
of looking at old information
Here-and-now Pointing out interactions with the Help the client gain insight about
process clinician that mirror interactions, reactions, attitudes, and behaviors
behaviors, attitudes, or reactions that occur predictably and per¬
also expressed with others haps inappropriately in multiple
contexts
Interpretation Providing explanations based on Help the client understand the
knowledge of the client about the reason behind the reactions, atti¬
origins of a client's reactions, be¬ tudes, behaviors, and so forth that
haviors, interactions, and so forth manifest frequently, predictably, or
inappropriately

phisticated words from their conversation. Although guidance and prodding are
most important in childhood, they remain of great value in adulthood. And this
is, of course, the link to psychotherapy and counseling. The cognitive interven¬
tions that will be discussed in this and the following chapter are conceptualized
as cognitive guidance and encouragement. They are designed to be used as a
means of facilitating clients’ cognitive growth to a more complex, abstract, logi¬
cal, informed, and flexible level of functioning. This goal can only be achieved
if the clinician can adapt language and intervention to the client’s current level
of cognition. Mental-health-care providers adapt their interventions and lan¬
guage to a different level of cognitive complexity when they work with children;
they need to do the same in their work with adults. As clinicians use the cogni¬
tive strategies that follow (and that are outlined in Table 8-2), they need to keep
the following points in mind:

• clinicians need to assess or appreciate clients’ cognitive capacity and style,

carefully differentiating optimal cognitive functioning from situational
impairment
222 CHAPTER EIGHT

• choice and style of implementation of cognitive strategies are adapted to

clients’ level of cognitive capacity in a given situation, and thus may differ
depending on situational impairment versus optimal functioning
• clinicians need to be attuned to the identification of forced assimilation
on the part of the client
• clinicians facilitate accommodation and organization through guidance
and encouragement, challenging the client toward cognitive growth
• interventions need to be phrased in a manner commensurate with
clients’ cognitive capacity and language skills, optimal and situational,
as appropriate
• statements have to be formulated as clearly and succinctly as possible
• information may need to be given at multiple cognitive levels to ensure
clients’ understanding
• statements are best formulated more concretely than complexly when a
choice is possible
• conversation optimally will be in clients’ native tongue
• language is best adapted to the preferences of clients (this does NOT
include the use of offensive or prejudicial language)
• language is best free of jargon
• if jargon is unavoidable, it needs to be clearly and simply defined

A Hierarchy of Interventions and Strategies

for Working with Thought and Cognition
The strategies for working with thought and cognition that are outlined in
Table 8-2 and discussed in this and the subsequent chapter offer a new way of
looking at the issues presented by a given client. All suggest a shift in clients’
perceptions or cognitive interpretations of an issue or situation at hand. All
strategies require cognitive skills on the part of the client, most importantly re¬
quiring clients to organize new schemata and to accommodate where neces¬
sary. Clearly, some amount of cognitive flexibility and creativity on the part of
the client will greatly facilitate success with these interventions. Guidance and
encouragement, as explained above, may be necessary to help clients make
therapeutic use of these interventions. The strategies will be presented hierar¬
chically, not only according to the level of cognitive complexity they require of
the client, but also according to a number of other therapeutically relevant is¬
sues. Specifically, the strategies, as ordered in this text (and in Table 8-2)

• require increasing levels of cognitive complexity and flexibility on the

part of the client
• require increasing levels of cognitive complexity and flexibility on the
part of the clinician
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 223

• create increasing levels of depth in the cognitive shift or insight that will
be achieved through their use
• require increasing levels of understanding and knowledge of a given
client by the clinician
• require increasingly stable rapport and sustaining attachment between
client and clinician
• will be increasingly reflective of die clinicians theoretical orientation

Given their characteristics presented in this listing, it is not surprising that

the strategies described earlier will be used earlier on in treatment and less and
less so later in therapy or counseling (though they may be used to some extent
throughout treatment with a given client). The strategies presented later, es¬
pecially the strategies presented in the advanced-cognitive-skills chapter, will
be used later in treatment with a given client, as they require more stable rap¬
port and more insight on the part of the mental-health-care provider about the
client. The strategies, as they grow increasingly complex, require more and
more complexity and insight on the part of the clinician. This is truly an area
where a clinicians own personal cognitive limitations may get in the way of
therapy and counseling. Advanced cognitive strategies, such as interpretation
and here-and-now processing, require that clinicians understand underlying
dynamics that are manifested in the clients symptoms and behaviors. Only
then can they help clients recognize inappropriate or irrelevant assimilations
and the need for shifts in existing schemata.
Increasingly, cognitive strategies will reflect clinicians’ personal theoretical
orientation. For example, although interpretation as a strategy in and of itself
is theory-free, the content placed in the interpretation will vary given the clini¬
cian’s own personal theoretical beliefs about what has motivated a given client’s
behavior, opinion, reaction, or attitude. Thus, a Rogerian may interpret a given
reaction of a client as evidence of personal incongruence, whereas an existen¬
tialist may understand it as a manifestation of existential angst; whereas a cog¬
nitive behaviorist may see it as evidence of automatic thinking that has become
maladaptive; and so on. Clearly, the use of higher-level cognitive strategies re¬
quires clinicians to be aware of their biases and values and how these may en¬
ter treatment. This issue will be addressed again as it becomes relevant to each
strategy under discussion.

Dealing with Clients’ Cognition-Related Crises in Session

The clinician needs to be prepared for a few contingencies in working with
thoughts and cognitions. Just as mental-health-care providers have to be pre¬
pared to deal with out-of-control emotions while working on helping clients gain
awareness of affect, so do they have to be prepared to deal with thoughts that
may spin out of control. The most common manifestations of problems revolve
around racing thoughts (usually associated with and recognized by pressured
224 CHAPTER EIGHT

speech) and dealing with psychotic symptoms, most commonly and relevantly,
delusions, but also hallucinations. A few guidelines are provided here to help
beginning clinicians deal with these situations. However, these interventions
are much less clear-cut than suggestions that are possible for out-of-control af¬
fects. Mental-health-care providers may find themselves making modifications
as client needs arise and as client idiosyncrasies manifest. Reading the material
on dealing with out-of-control emotions in the affective-awareness chapter will
help clarify some of the suggestions below.

Dealing with Thought Racing and Pressured Speech

If the primary problem appears to be that the client’s thoughts are racing and
resulting in pressured speech, the mental-health-care provider intervenes with
calming strategies. The clinician begins by asking the client to stop talking al¬
together and to begin breathing and relaxing. The clinician asks the client to
pattern her or his breathing after the therapist’s. (For example: “Let’s get your
breathing back to normal. Follow my lead. Slowly breathe in ... [clinician takes
a long, calm breath] and out. . . [clinician releases the breath forcefully]-, in . ..
and out . . .) This joint rhythm of breathing is maintained until the client be¬
comes notably calmer. The client is asked to model breathing according to the
therapist’s example and not to talk during this exercise. The simple breathing
can be kept up for some time if the clinician believes that it is sufficient in slow¬
ing down the client’s thought process. If the client’s thoughts appear to con¬
tinue to race (as perhaps suggested by a difficulty in slowing down the breath¬
ing or fidgety psychomotor behavior), a focal-point exercise can be added. The
client is asked to find a focal point and to place her or his total attention on it.
Once the client has established eye contact with the focal point (for example, a
picture in the therapy room), the client is asked to describe it. (For example: “I
need you to look at... right there across from you. Okay, now tell me what you
see. Describe it in detail”) This simple task serves to distract the client’s focus
of attention away from the racing thoughts. The client may need some assis¬
tance, as thoughts may be highly preoccupied. If this is so, the counselor may
need to do some modeling of description. (For example: “Okay—what do you
see? I see a brown picture frame—do you see it? Okay . . . What shape does it
have? . . . Yes, that’s how I see it; it’s almost square. . . . What else?” and so on.)
Overall the focus is on helping the client stop thinking about the obsessive
thoughts to slow cognitive processing and to model calmness and relaxation
through calm breathing, controlled body language, low and slow voice, and
firm directives about what the client needs to do next. The focal-attention ex¬
ercise is generally very successful with these clients.
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 225

dealing with Delusions and Hallucinations

The key to successful intervention with a client who is experiencing a psychotic
break is to reestablish psychological contact with the person. Counselors fre¬
quently and calmly use clients’ names to get their attention. Clinicians respond
with calmness to clients’ hallucinations or delusions to make psychological con¬
tact and do not get caught up in the psychotic content of the delusions or hal¬
lucinations the client is describing. It is best to respond to delusions and hallu¬
cinations by listening and expressing caring and concern without encouraging
or validating the psychotic content. In other words, delusions are neither chal¬
lenged nor argued with; instead, the clinician focuses on giving the client a
sense of being heard and understood. It is very likely that the client is used to
being the target of ridicule, challenge, and harassment when voicing delusional
thinking or while talking about specific hallucinations; it is important to provide
an alternative experience. An understanding and accepting attitude by the clini¬
cian is very useful in these instances and greatly facilitates psychological contact.
The second goal is to reestablish contact with reality. This is accomplished
not by challenging the delusional content of the clients verbalizations or by
challenging the reality of the perceptions, but rather by redirecting the client
toward a here-and-now concern. (For example: “I understand what you are say¬
ing. Tell me, how did you deal with your son when you heard this voice telling
you to kill yourself?” And then “And what do you do to get your son to daycare
on time when this happens?” and similar interventions to get the client refo¬
cused on a real but related problem.) It is also important to explore and then
allay any fears stemming from the hallucination or delusion by asserting the
clinicians awareness of reality. (For example: “I understand your fear, but
please let me assure you that I can guarantee you that Satan is not in this room
with us.”) If there is a kernel of truth to a clients delusion (and there usually is),
it is important to find it and to respond to it. (For example: “I believe that you
have been followed, especially that one time you told me about when . . . Can
you tell me more about THAT incident?”)
While reestablishing psychological contact and some degree of touch with
reality, counselors remain calm and focused themselves, being careful not to be¬
come frightened of the client and not to be persuaded to reinforce the client’s
delusions. It is quite possible to express understanding as to why the client may
have certain thoughts or beliefs without suggesting that the counselor shares
them. It is also quite possible to acknowledge that the client is hearing or see¬
ing things and that this is distressing, while remaining clear that others do not
hear or see these same things. It is important to maintain an empathic stance
that provides understanding and guidance. In other words, it is not enough to
keep the client happy by giving emotional support; it also important to set firm
limits on the clients behavior to ensure the clients and the clinician’s safety.
(For example: “I need you to do xyz before we can go on,” or “I understand you
226 CHAPTER EIGHT

feel. . .; however, right now we need to do ... to keep you safe.”) A final note
is necessary here: Despite their portrayal in the media to the contrary, psychotic
individuals are no more dangerous and no more aggressive than the general pop¬
ulation. They certainly can be aggressive (especially if their delusions involve
paranoia or if clients experience a need to defend themselves from a threat).
However, more often than not, aggression is not something the clinician has to
fear from the psychotic client. As a rule of thumb, it is more important to get
the client reoriented than to worry about physical safety. Obviously, if the cli¬
ent cannot be reoriented, the in-session intervention may need to end with the
institutionalization of the client. A client is typically not allowed to leave the
clinician’s office alone and without a follow-up plan while flagrantly psychotic
(see Brems, 2000, for more detail).

Basic Strategies for Working

with Thought and Cognition

The common thread that ties together the basic strategies theoretically is their
straightforward and nonchallenging nature. These strategies require less cog¬
nitive complexity on the part of the client than confrontation, here-and-now
processing, or interpretation. All are focused, at least to some extent, on in¬
creasing the clients fund of information, either about life in general (as in Im¬
parting Information) or about the client in particular. The patterns that are
pointed out or the questions that are asked are clear and sufficiently straight¬
forward that the client does not have to have enormous abstracting ability to
understand what the clinician is driving at. Minimal effort is usually required
on the part of the clinician to help the client recognize the point the clinician
can already see. These strategies are also rarely perceived by the client as a chal¬
lenge or a criticism, a danger that lurks in the use of the more advanced tech¬
niques. These strategies not infrequently lead to an increase in the client fund
of information or a shift in the client s way of understanding a situation that in
and of itself is sufficient to alter the client’s attitude about or opinion of a given
issue. The three categories of strategies that meet this description most accu¬
rately are those of Imparting Information, Pointing Out Patterns, and Asking
Clarifying Questions. This is not to say that these strategies will always be ba¬
sic; at times, clinicians may make very complex points by merely pointing out
a pattern or asking a few clarifying questions. The fact is, however, that all of
these strategies can be used in a straightforward manner (they just do not al¬
ways have to be used that way).
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 227

Imparting Information
Many clinicians may not even consider imparting information as a therapeutic
strategy, viewing it instead as an educational intervention. In either case, most
do end up using this strategy at one point or another. Whether it is therapeutic
or educational is somewhat irrelevant; clinicians need to know how and when
to use it, and perhaps even more important, when not to use it. Although im¬
parting information is the first cognitive strategy presented, it is not used very
often in counseling and therapy. It is merely first because of its low level of
complexity. If the hierarchy had been arranged with regard to how often strate¬
gies are likely to be used, imparting information would have ranked last, be¬
hind all other cognitive strategies.
Potential pitfalls of imparting information are many and need to be con¬
sidered before (over)using this simple intervention. Imparting of information
is most appropriate when a client appears to be operating under a set of factual
information that is faulty, inadequate, or incomplete. The emphasis of this
definition is on factual. The information in question is not a set of values or
opinions; it is truly a set of facts that can either be verified or disproven. The
decision to correct a client’s factual set of information by imparting new, dif¬
ferent, or additional information is a difficult one. Not all sets of factual infor¬
mation that meet one of the criteria (that is, are incomplete, inadequate, or in¬
correct) need to be addressed. If they are irrelevant to the issue at hand, are
not part of why the client seeks treatment, or seem to play no role in the client s
presenting concern, the clinician may not feel obliged to correct the client.
However, if the imparting of information may lead to a revision, updating, ex¬
pansion, or completion of a factual set of information for the client, which in
turn may lead the client to have a different response to a situation that is re¬
lated to or relevant for the presenting concern, such an intervention may not
only be appropriate but necessary.
In using this strategy, counselors need to be careful to not come across as
condescending or arrogant. Sharing information is a joyful and helpful process,
not a means of demonstrating superior knowledge or greater value or skill.
However, because clients may perceive the imparting of information as some¬
thing that demonstrates that they are less educated or “smart” than their ther¬
apist, it is used sparingly and when used is done matter-of-factly and carefully.
Before imparting information it is always useful to be certain about what
the client does and does not know. Sometimes clients may appear to know less
than they do. Then imparting information would be ill advised because the
client actually knows but just does not disclose. Therefore, imparting informa¬
tion is best done in manner that looks like a joint exploration of a subject to
which both client and clinician contribute what they know. This way the dis¬
cussion is balanced and the clinician is not perceived as merely “preaching” or
“lecturing” to the client.
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 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 229

Imparting information can take at least three forms. These three forms can
occur separately or may co-occur in a single intervention. A comparison and
overview is provided in Table 8-3.

Psychoeducation
First, imparting information can focus on providing information the client does
not (yet) have about a psychological or development process, a strategy often
referred to as psychoeducation. Psychoeducation is often a strategy of choice
for group therapy interventions, and is the process that occurs in groups ad¬
vertising parenting education, anger management, stress reduction, and so
forth. Psychoeducation can occur in individual treatment whenever the clini¬
cian deems it important to give the client information about a particular topic,
be that parenting, developmental milestones of children, facts about sexuality,
or resources about relevant workshops in a community. The commonality of all
psychoeducation rests in the fact that the clinician merely imparts objective in¬
formation and does not make value judgments or give opinions, but merely in¬
forms the client about a topic area of relevance or concern. For example, a clini¬
cian working with an adolescent who is becoming sexually active may take the
responsibility to talk with the client about contraception, sexually transmitted
disease, and so forth. It is possible for psychoeducation to lead to a discussion
of values. Hardly any topic of relevance is going to be free of values. However,
the focus of the information imparting is strictly on objective facts of which the
clinician is aware and the client appears not to be. Once the client has the facts,
therapeutic work can be done around the behavior and whether the client
wants to choose to engage in it. That is a separate issue and would no longer be
considered imparting of information. Teasing out fact from opinion can be
difficult at times. The best rule of thumb is that if information is based in
knowledge gleaned from scientific sources (professional journals, professional
conferences, textbooks), it can be considered more or less factual and objec¬
tive; if it is based on popular sources (television, magazines, newspapers), it
may better be considered opinion. If it appears to be opinion, the clinician
should first do some reading in scientific sources before using imparting infor¬
mation as a strategy. Psychoeducation is never the only therapeutic strategy
employed by a counselor. It is best kept brief and embedded in a larger thera¬
peutic context.

Normalization
The second form of imparting information provides information about the uni¬
versal or normal nature of a client reaction to a situation others have encoun¬
tered as well, a strategy often referred to as normalization or universalization.
This strategy can be used successfully when a client questions a reaction in the
self that the clinician recognizes to be appropriate, perhaps even healthy. A
230 CHAPTER EIGHT

common example of this form of imparting information is the educating of a

rape victim about the normal stress response that follows the assault. Many
women, in the aftermath of a rape or similar traumatic occurrence, question
their adjustment, especially when others in their environment minimize the
enormity of the experience. Helping a woman recognize that her reactions are
completely within the norm of what other women in similar situations experi¬
ence can be healing and calming. If more information is given about what to
expect and how to prevent additional problems in the future, psychoeducation
is being added to normalization.
The label of what clinicians are doing is less important than the recogni¬
tion that they are imparting information and hence need to remain objective,
factual, and as free of values as possible. Once the information has been shared,
processing may occur that deals with the value-laden and decision-making
(that is, tmly therapeutic) aspects of the situation at hand.
One important caution is indicated here. A therapist must never normal¬
ize or universalize a client response that is not healthy, adaptive, or common,
even if the client desperately wants the clinician to do so. If a client s reaction
falls out of the norm of what counselors might expect, they must not be
tempted into saying that the reaction is normal because the client is asking for
such feedback. Normalization is used sparingly, never used dishonestly, and not
used in isolation but only contextually.

Relabeling
Third, imparting information can consist of providing an alternative label or
viewpoint for a situation with which the client is struggling, a process that is of¬
ten called relabeling, reframing, or refocusing. An example of the use of this
strategy may be to relabel as “protective” a parent whom the client labeled as
“nosey.” Similarly, reframing may consist of the clinician labeling the client who
refers to the self as “cowardly” as “careful” or “cautious.” The new label changes
the perspective, basically giving the client a new way to look at old data. In that
sense it imparts information, information about how to look at the same situa¬
tion through a different filter. It could be argued that this strategy goes some¬
what beyond imparting of information as it may not be entirely factual, but may
begin to introduce some subjective reinterpretation of a situation by the clini¬
cian. It is not important to settle this argument. What is important is to under¬
stand that the strategy should stay as objective and factual as possible. If the
client truly was “cowardly,” the clinician would not have chosen to reframe; the
new label of “cautious” would only be suggested if the clinician truly believed
it to be a more accurate description of reality. In other words, reframing or re¬
labeling needs to be so clear-cut that consensus would likely exist across prac¬
titioners as to its appropriateness. If the clinician wonders whether the re¬
framing or relabeling reflects personal values or may be inaccurate, it may be
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 231

better not to use it. On the other hand, some subjectivity may enter all of these
strategies and thus it is difficult to tease out when relabeling stops being a strat-
egy of imparting information. Perhaps one of the most important issues is to
make sure that the reframing process is presented in such a way that the client
can understand what the clinician understands, both cognitively and emotion¬
ally. That is, the suggestion of a different label or of a different way of looking
at a situation must resonate with the client to be effective. If the client cannot
understand what the clinician is trying to do because the counselor presents
the new label in a way that exceeds the client s cognitive capacity, then the
strategy will obviously fail. Similarly, a client may not be emotionally ready to
let go of a particular way of labeling or viewing a situation. In such a situation,
the strategy will not lead to the desired outcome. At each step the clinician
is advised not to argue with a client who rejects an attempt at relabeling or
reframing.

Sample Transcript of Imparting Information

The sample transcript that follows shows how a clinician uses imparting infor¬
mation to arrive at a therapeutic aim. The sample shows how mental-health-
care providers frequently mix psychoeducation, normalization, and relabeling
in imparting information. It also demonstrates a collaborative way of imparting
information in that both client and clinician share what knowledge they have.
This approach reduces the risk of the client feeling “dumb” or lectured to. As
each form of imparting information is used, it is identified in parentheses to
help the reader follow what is happening. The sample also includes a few in¬
appropriate uses of imparting information (also clearly labeled as such) to show
how easy it is to misuse these strategies. The reader is encouraged to review
Table 8-3 one more time, with particular attention to the cautions and poten¬
tial pitfalls of each of these strategies.

CLIENT: I am just not ready to do that, but my husband is really pushing

me to do it. Its actually pretty scary, you know.
CLINICIAN: Tell me more. . . .
CLIENT: Well, this is how it is. He thinks that the best way to go is to
have a mammogram every six months. But I’m really afraid of the radia¬
tion exposure. I guess we have always had a different approach about that
land of tiling.
CLINICIAN: You have?
CLIENT: Yes. I don’t really believe in just using traditional medicine for
anything, but he obviously does. I mean he is a surgeon after all. I guess
I should be glad that he doesn’t just want me to go ahead and have a pre¬
ventive mastectomy.
CLINICIAN: Was that an option you discussed?
232 CHAPTER EIGHT

CLIENT: Yes, but even he seemed disinclined. . . . Just because of a

benign lump—That would be pretty radical.
CLINICIAN: Why the mammograms?

CLIENT: Well, he thinks that because my mother died from breast cancer
and now I had this lump removed I’m at pretty high risk. . . .
clinician: What do you think your risk is? (exploring whether the client
has sufficient information or if she needs more)
CLIENT: Oh, I know he is right. I am high risk. There’s my mother, my
history of lumps. . . .
clinician: Anything else? (following up on the need for education here)
CLIENT: Well, it’s kind of embarrassing, but I don’t really know what
other risk factors he’s talking about. He just says to believe him. I guess I
ought to be looking into that a bit. . . .
clinician: That’s a great idea. It always helps to learn about things you
have to make decisions about. Would you like me to run through some of
the risk factors with you?
CLIENT: Oh, do you know them? That would be great.
clinician: Well, I know a few more that we can talk about. But I still
think it would be a good idea for you to check out more, regardless of
what we come up with, okay? You know I’m not a physician. . . .
CLIENT: I know. . . . What are some other risks?
clinician: Well, let’s see. There is diet. What kind of diet do you have?
CLIENT: (explains her diet in detail; clinician follows up with a number
of questions)
CLINICIAN: (explains which aspects of the client’s diet appear to be asso¬
ciated with higher risk and which appear helpful) (psychoeducation)
CLIENT: Anything else besides diet?
CLINICIAN: Well, there is risk associated with how many years a woman
actively ovulates. So we could look at when you started menstruating,
how many pregnancies you had, and things like that
CLIENT: (provides information in detail; clinician follows up with a few
additional questions)
CLINICIAN: (responds with what the client’s information may mean)
(psychoeducation )
CLIENT: Wow, this is a lot of information. Is there more?
clinician: There can be environmental factors. Like exposure to cer¬
tain chemicals, pollution, radiation exposure . . .
CLIENT: Yes, I know that! Well, you know, I guess I know more than I re¬
alized. I have been worried about radiation exposure. In fact, that’s what
the whole mammogram argument is about.
clinician: (realizing her mistake of not catching this nuance sooner)
Of course. I should have picked up on that. You did mention that you
worried about radiation exposure. Just X-rays, or other kinds, too?
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 233

CLIENT: Mainly X-rays. See, when I was a little girl I had breathing
problems. Back then they didn’t worry much about X-rays so I had lots
of them. Of my lungs. Well, you can see my concern because when they
X-ray your lungs, your whole chest is exposed.
CLINICIAN: Of course. So how many X-rays do you think you had?
CLIENT: Oh, at least two a year for several years there. I’ve lost track.
I’d really have to think about it. Maybe there weren’t really all that many.
So I guess you must think I’m nuts for worrying so much about X-rays.
My husband does. I guess maybe I’m a little extreme. But it really
scares me!
clinician: It seems to me that you are not excessively scared. Your con¬
cerns seem very reasonable and realistic to me. (Normalization)
CLIENT: They do?! (relieved) So do you think I should have the
mammograms?
clinician: That’s not a decision anyone can make for you. It’s your body
and you’ll have to decide that for yourself. What do you think you need to
do? It’s your decision. . . .
CLIENT: Well, my husband doesn’t think so. He thinks he should make
the decision for me because he is the physician and he knows better.
You know, he is smarter about these things than I and so I should listen
to him. . . .
CLINICIAN: Is that what you want?
CLIENT: Well, not really. But I know he’s just worried about me. He just
wants to help me make this decision. . . .
CLINICIAN: He wants to control your decision, (an inappropriate relabel¬
ing that reflects a value judgment on the clinician’s part)
CLIENT: Oh . . . Oh my . . . Do you think so? He can be controlling, you
know. It comes with his job. (a little defensive)
CLINICIAN: My apologies. That was a little judgmental on my part. Do
you perceive it as controlling? (apologizes but realizes she cannot take the
judgment back, so tries to work with it)
CLIENT: Well, I never thought of it as controlling.
CLINICIAN: Okay, then it probably isn’t—my mistake. So your husband
may be trying to be helpful in the best way he can, and he thinks you
should have the mammogram. What would you like to do? (getting back
to the issue at hand)
CLIENT: I don’t want it! I am scared of it! My sister is refusing them.

My husband calls her extreme.

CLINICIAN: Do you think that’s a fair label? (tries to get client to relabel
on her own)
CLIENT: No. I think she is being smart and cautious! (client does the job)

CLINICIAN: That does seem to be a better perspective on her

behavior. . . .
234 CHAPTER EIGHT

CLIENT: Yeah; she knows what she’s talking about. She gave me some
studies to read that show that mammograms can create problems be¬
cause of the radiation and that they can spread existing disease.
CLINICIAN: It’s good for you to realize that you have information already.
Earlier you seemed to imply that you didn’t. . . .
CLIENT: Oh, I forget sometimes. You know, my sister and I, we read a lot
about mammograms after Mom died because we were trying to figure
out what we should do. Being high risk and all.
clinician: Back then what did you decide?
CLIENT: That it wasn’t worth it. In other countries they don’t recom¬
mend annual mammograms anymore. I forget why. I wish I could re¬
member details like that better. . . .
clinician: Because they don’t really extend life span. They may detect
disease earlier, but they do not extend lifespans, and they can increase
risk due to radiation, (psychoeducation that may or may not have been
appropriate because the client may have been able to retrieve the infor¬
mation from her memory with a bit of prodding)
client: That’s it. Now I remember. They also detect a certain kind of
cancer that may not ever even do anything to the woman.
clinician: CIS, carcinoma in situ. Cancers that are well encapsulated
and may never spread and grow.
CLIENT: Right, the kind they used to find in autopsies of women who
died of old age or other things but not because of cancer.
clinician: Right. And so the theory is that these land of cancers are
now overdetected and overoperated on. (psychoeducation that was un¬
necessary and may have been perceived as trying to sway the client in a
certain direction in her decision making)
CLIENT: Yes, I remember these things now. I’m glad you are helping me
fill in the gaps. I really think I’m going to just keep doing what I’ve been
doing. No mammograms, just monthly self-exams.
clinician: That is how you found this recent lump, isn’t it?
client: Yes. I hate doing them, you know. . ..
clinician: The monthly self-exams?
CLIENT: Yeah. I am always terrified of what I might find. Crazy, isn’t it?
clinician: Seems pretty understandable to me. (Normalization)
CLIENT: Really? Do other women go through this agony every month?
CLINICIAN: Many women with your history probably do. (repeats the
normalization )
CLIENT: Well, that’s it then. I’ll keep doing the BSE [breast self-exam]
and I won’t do the mammograms. I think that’s a good course of action.
What do you think?
CLINICIAN: Does it feel right to you?
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 235

CLIENT: Yes, though I have to say I wish there were other things I
could do.
CLINICIAN: Well, there might be. There are other methods of detection.
They are not all perceived as acceptable by traditional physicians but
many women swear by them, as do some alternative physicians and a
number of researchers.
CLIENT: Wow. I haven’t heard that. What else is there?
CLINICIAN: Well, for one thing there are ultrasounds. They are safe and
can be quite effective in detecting certain types of lumps. There are also
devices that you can use to make your BSE more sensitive, (adds more
psychoeducation about nontraditional methods of early detection)
CLIENT: Wow. I will check some of these things out.
CLINICIAN: Do that. You will have to make your own choices, but it
helps to be fully informed.
(Session continues from there.)

This transcript shows how imparting information can be done in a back-

and-forth manner so that it does not feel like a lecture to the client. Therapist
and client collaboratively help the client fill in knowledge gaps that may be im¬
portant to her decision making. The transcript also demonstrates that impart¬
ing information is obviously only possible if the clinician is informed and has
information to share. A clinician who knows nothing about breast cancer or
mammograms could not have helped the client in the same way as this coun¬
selor. She would have had to encourage the client to seek out information on
her own and then would have had to do some reading herself. It is very dan¬
gerous to impart information that is opinion-based rather than based on fact.
Many clinicians might have fallen into the trap of agreeing with the husband’s
recommendation based on popular opinion and media exposure. Luckily for
this client, her clinician was informed and thus able to lead the client to make
her own decision. The transcript also demonstrates the fine line between fact
and opinion. Much of what clinicians perceive as fact is actually opinion, often
based on information shared by the popular media. Since the popular media
are not always accurate in their representation of scientific fact, clinicians need
to be aware that when they impart information they need to have a source for
that information other than television, newspapers, and magazines.

Pointing Out Patterns

Pointing out patterns is about raising client’s awareness to the reality that there
are certain habitual ways of relating or responding that have developed over
time in the person’s life and that may or may not be adaptive and useful. For clini¬
cians to be able to use this very effective strategy, they obviously have to be
236 CHAPTER EIGHT

attuned to the fact that clients manifest such patterns to begin with. It is help¬
ful to explore where, why, and how patterns tend to emerge.
Clients may manifest at least four types of repetitive themes or patterns in
their lives (cf., Teyber, 1997). The first kind of pattern that may be noticed is
relational patterns. Relational patterns are interpersonal scenarios that the
client plays out over and over again with a variety of people in a variety of con¬
texts. For example, a clinician has identified a relational pattern if noticing that
a client reacts with hostility to all authority figures, or that a client becomes
anxious around all people of the opposite gender. These are examples of very
simple interpersonal patterns that are often easily recognized. At times, inter-
personal patterns can be subtler. For example, an interpersonal or relational pat¬
tern is present if a client tells multiple stories of having been used by friends.
The clinician may recognize after a few of these stories that the client appears
overly sensitive to being taken advantage of and may actually misinterpret
friends’ actions or intent. Relational patterns are some of the more easily rec¬
ognized patterns, especially since they may even be detected or played out in
the relationship with the clinician.
A second type of pattern that clients can manifest is one that consists of
rigid cognitive beliefs. These core beliefs underlie and maintain a repetitive
pattern of reactions that may include behaviors or emotions and that reflect se¬
lective and repetitive bias in cognitive processing. These patterns may only be¬
come clear as cognitive patterns after the clinician has recognized that a variety
of apparently diverse behaviors, reactions, and affects are actually all traceable
to the same basic underlying cognitive belief or distortion. The clinician may
not recognize the common thread that ties these diverse events together until
suddenly the connection becomes clear. For example, a client may have told
the clinician of feeling enraged after a certain event in her life. The next session,
the same client may report having overslept several times that week. Finally, she
may relate having experienced a severe lapse in self-confidence after a particu¬
lar work incident. The clinician may not recognize until some thorough explora¬
tion of the events and the client s reaction to them that the same cognitive pat¬
tern explains all of the clients reactions: her anger, her oversleeping, and her
lapse in self-confidence. Specifically, the clinician may recognize that during or
after each event, the client (inappropriately or irrationally) took all blame for
the occurrence on her own shoulders, reinforcing her belief that she is not per¬
forming up to her own standards for herself. One reaction to her self-blame
may be rage or anger about perceived slights in the other person involved in
the event, a not-uncommon way in which clients externalize (or project) self¬
blame; another may be excessive concern about future work performance which
leads her to oversleep as a means of avoiding work altogether; another and most
obvious tie can be made to the clients fading self-esteem. Thus, there are three
apparently different responses, but one underlying cognitive theme of self¬
blame and over-assumption of responsibility.
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 237

A third type of pattern that can emerge is related to core affects. Core af¬
fects are long-standing and recurring, reflecting an affective style that is main¬
tained by the client across situations and contexts, regardless of circumstances.
Such a client may respond with depression to all different types of situations,
even those that are actually joyous or at least neutral. Core affects can also be
called default affects and are described in the affect-related chapters. Core af¬
fects are generally easily recognizable as the client will manifest the affect in
session with the clinician. They may be somewhat more subtle if the client is
not aware of the affect but still has some outward expressions of it.
A final pattern is recognized in habitual behavior. Habitual behavior is ba¬
sically similar in nature to core beliefs or default affects in that the client has a
certain behavior pattern to which she or he resorts in any and all relational,
cognitive, and affective contexts. No matter what die external event, the client
responds with the same behavior. These patterns lead to almost-automatic re¬
sponses that leave the client trapped in behaviors that have long outlived their
adaptiveness and usefulness. For example, a client who yells when he is happy,
yells when he is sad, or when things go wrong at work, or yells when he dis¬
agrees with his wife manifests a behavioral pattern. Clearly, behavioral patterns
tend to be easily recognized as they will usually show up in session as well. The
client in the example will sooner or later yell at the clinician, and the clinician
will have a firsthand experience of how the client s behavioral pattern plays out
in interpersonal contexts.
Although it is generally easy for clinicians to pick up on a client s patterns,
it is surprisingly difficult for clients to recognize them. They often fail to real¬
ize that they react to certain people in the same way over and over again (rela¬
tional pattern); they fail to be aware that the same thoughts tend to run through
their minds in all different types of situations and with all different types of
people (cognitive patterns); they do not recognize that they behave identically
with many different people and in many contexts (behavioral patterns); in fact,
they may not even be fully aware that they react with the same emotion to situ¬
ations that do not elicit such an affective response in others (affective patterns).
Clients tend to develop patterns for a reason. Patterns usually served an
adaptive function at their inception, which is often traceable to childhood
learning or learning that was salient in adulthood. Patterns are reactions that
are predictable and habitual and generally maladaptive. But they did not start
out that way. They often started out as the clients best effort at self-protection
and at dealing with difficult circumstances. Because of this history, patterns are
difficult to break. The purpose of pointing out patterns is not their discontinu¬
ation. Instead, pointing out patterns has the primary purpose of helping clients
become self-aware so that they can begin to recognize the patterns and to iden¬
tify the habitual responding (whether affective, relational, cognitive, or behav¬
ioral) as it occurs. Once clients have become aware of how certain patterns re¬
peat themselves in their lives and how they manifest either behaviorally,
238 CHAPTER EIGHT

cognitively, affectively, or interpersonally, they will often become curious about

why the pattern developed in the first place. This curiosity in turn often leads
to explorations of the origins of the patterns and an explanation (or interpreta¬
tion) of the purposes they once served. Once the client has recognized the orig¬
inal purpose as well as the outdatedness of that purpose, the pattern can usu¬
ally disappear on it own. However, the simple strategy of pointing out patterns
does not concern itself with this exploration, which is actually in the realm of
confrontation, here-and-now processing, or interpretation.
The pointing out of patterns as a basic cognitive therapeutic technique
simply consists of a therapists repeating events, reactions, or contents the
client has communicated over time to identify a common thread (relational, af¬
fective, cognitive, or behavioral) that ties all of them together. This common
thread is pointed out to clients to help them recognize that apparently discon¬
nected events or reactions are actually reflections of a single process or symp¬
toms of a single problem. Once the pattern is pointed out, the client is en¬
couraged to look for it on a day-to-day basis. If the client is open to it, this work
will proceed quickly both in and outside of sessions. While in sessions, the clini¬
cian will continue to point out patterns that have now been identified to the
client. This needs to be done respectfully and caringly so that the client does
not feel judged or made fun of. As clients improve their detection skills they of¬
ten begin to recognize patterns independently and then begin to recognize that
they have response choices of which they were not previously aware. Thus, al¬
though the primary and initial goal of this basic strategy is merely awareness
raising, the ultimate outcome is often insight and behavior change.
What follows is an example of a simple process of pointing out a pattern to
a client who has a habitual way of relating to others. The example demonstrates
the ease with which this strategy can be implemented. However, not all inci¬
dences of pointing out patterns are this straightforward. In fact, the next sec¬
tion (clarifying questions) will provide an example that uses careful question¬
ing to point out a more subtle and less straightforward pattern in the same
client.

CLIENT: Well, that’s pretty much all that happened. Dorothy hung up
the phone. I haven’t heard from her since.
clinician: That’s all? You disagreed about whether to go see a movie
and she hung up on you?
CLIENT: That about wraps it up.
clinician: Nothing else happened?
CLIENT: Nope.
CLINICIAN: So, that’s pretty similar to what happened with your mother
last month, right? You were talking on the phone, and then suddenly she
says she’s done talking to you.
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 239

CLIENT: Yup. Said she didn’t need to listen to me that way and
hung up. . . .
CLINICIAN: Listen to you what way?
CLIENT: I don’t know what she was talking about. . . .
CLINICIAN: You don’t?
CLIENT: Nope.
CLINICIAN: Seems to me this has happened to you a few other times.
I recall you said that your ex-wife used to storm out when you had
arguments.
CLIENT: Yeah, she did. She just didn’t like to argue, I think. You know, I
think she just couldn’t handle it when we disagreed. So her way of getting
out of it was to just walk out.
clinician: And nothing you did made a difference?
CLIENT: I don’t think so . . . but that was a few years ago, you know.
clinician: Have other people cut conversations short with you?
CLIENT: I’m not sure ... at work maybe. Sometimes my boss says that
she won’t tolerate my talking to her like that and that we’ll finish talking
when I calm down.
CLINICIAN: When you calm down? What does she mean by that?
CLIENT: I guess I get a little worked up when I talk with her at times.
CLINICIAN: And what does that look like?
CLIENT: When I get worked up?
CLINICIAN: Uh huh . . .
CLIENT: Oh, I guess I get emphatic.
CLINICIAN: As in loud?
CLIENT: I guess so. . . . (grins sheepishly)
CLINICIAN: Isn’t that what Dorothy said, too, the other day?
client: Yeah . . .
CLINICIAN: She said something about yelling, right?
CLIENT: I guess . . .
clinician: And I seem to recall that when we talked last time about the
phone call with your mother, you said she said something like she didn’t
need to listen to you yell at her. . . . Am I remembering that right?
CLIENT: I suppose so. I guess I kinda forgot about that. . . .
CLINICIAN: So do you notice a pattern here? Do people really just
stop talking to you randomly, or is there something else going on at
the time?
CLIENT: A pattern? (not wanting to admit to it)
CLINICIAN: Yes, a pattern . . .
CLIENT: Like what?
CLINICIAN: Like you yelling and people deciding they don’t want to be

yelled at.
240 CHAPTER EIGHT

CLIENT: Yeah. Oh man, it was easier to think that they just quit talking to
me because of no reason at all.
CLINICIAN: But I guess they have a reason, at least from their perspec¬
tive, huh?
CLIENT: I suppose they do. No one likes a yeller.
clinician: No, not really. Could you see why they might want to quit
talking to you when you yell?
CLIENT: Well, I do get pretty loud. . . .
CLINICIAN: And you are not exactly small. . . .
CLIENT: Do I intimidate?
CLINICIAN: What do you think?

CLIENT: Oh my god. You know, I do this with my kids, too. They just
can’t walk away from me because I don’t let them.
clinician: Tell me more about that. (Session continues from here.)

This example shows how the clinician slowly helps the client recognize his
own relational pattern. She had become aware of his tendency to raise his voice
from interactions in session, as well as many different stories about relation¬
ships that had been problematic. However, she chose to point out the pattern
cautiously and step by step, almost allowing the client to arrive at the recogni¬
tion of the pattern on his own. When he showed himself disinclined to open his
awareness to the fact that he yells a lot, she became increasingly direct about
her observations and recollections. Finally, the client had to own the pattern
and did so. The clinician could just have pointed the pattern out directly but
believed that this lengthier and more indirect route of helping the client notice
it on his own would be more impactful and effective. It is usually preferable to
allow clients to recognize their patterns by pointing diem out piece by piece as
was done in this example, rather than to just hit them over the head with an ob¬
servation. Clients are always more open to understandings, awarenesses, and
insights that they actively help shape and unearth.

Asking Clarifying Questions

It is a somewhat arbitrary decision to call clarifying questions a strategy in their
own right. Clarifying questions can essentially be used for any type of cognitive
strategy, all the way from the most basic reframing (see example under Im¬
parting Infornmtion above) to the most sophisticated interpretation (see inter¬
pretation sample in the next chapter). Since they can also be used in a way diat
may not be covered by the other techniques, it appeared best to include them
as a separate strategy. Again, semantics are not important; the important issue
is that the new mental-health-care provider knows how to use questions to
work with thoughts and cognitions.
It may be best to start by briefly recalling how clarifying questions differ
from open-ended questions and systematic inquiries. Open-ended questions
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 241

have as their primary purpose to keep communication going between client

and clinician. The clinician pursues areas of inquiry without having a clear goal
or path in mind. Systematic inquiry is used to explore a certain topic area and
is focused on collecting data or increasing the fund of information the clinician
has about the client. As was true for open-ended questions, the clinician has no
preconceived notion about where the questioning will lead and is not trying to
lead the client down a particular path or toward a particular insight. Clarifying
questions, on the other hand, are planfully and purposefully asked to lead the
client to a recognition, insight, conceptualization, or understanding that the
clinician has already developed about the clients thoughts, affects, behaviors,
or relationships. The clinician uses clarifying questions to prod the client to¬
ward an understanding the clinician has gained about the client that the client
does not yet have but seems capable of deducing with some help. When using
clarifying questions, the therapist has a goal in mind; the counselor is leading
the client down a predetermined path of self-discovery. Clarifying questions
are the essential therapeutic strategy that is used to allow clients to come up
with their own insights and to own their own discoveries in treatment. It is
through the use of clarifying questions that clinicians invite clients to make dis¬
coveries about themselves that were really already present in their mind but
had not yet been verbalized or consciously formulated. It is the ultimate strat¬
egy for allowing clients to own their own progress and to take credit for their
own discoveries, awareness, insights, and progress. Sometimes clients will rec¬
ognize that the clinician led them to an insight through questioning; often,
however, they will not be aware that they were coached to a discovery. The lat¬
ter situation is preferable as it will lead to the truest ownership of the under¬
standing or insight achieved by the client. If the client does recognize that the
clinician led through questioning, it will be helpful to downplay the counselor s
role in leading the client to the insight and to encourage the client to take credit
for the discovery.
It is, of course, the very fact that clarifying questions allow the client to
take credit for a therapeutic understanding or insight that makes these kinds of
questions so useful in the realm of cognitive work and that makes them the pri¬
mary means of implementing most other cognitive strategies. Thus, although
the primary purpose of clarifying questions can be defined as a strategy that
leads the client to an insight or understanding at which the clinician had al¬
ready arrived, clarifying questions can also be used for many other purposes.
Specifically, they can lead to the same desired outcomes and meet the same
goals as strategies that

. educate
. reframe
. normalize
. point out patterns
 242 CHAPTER EIGHT

• problem-solve
• generate solutions
• reveal contradictions
• uncover incongruence
• result in insights about habitual patterns of relating
• reveal transferences
• explain behaviors, thoughts, affects, and interactions
• create understanding and self-awareness
• create insight about causes for behaviors, thoughts, affect,
and interactions

In other words, clarifying questions can be used for psychoeducation, re¬

labeling, universalization, pointing out patterns, confrontation, here-and-now
process, and interpretations. As such, they can be very basic techniques for
working with cognition and thought, or they can be highly advanced tech¬
niques. They are truly the bridge between the less and more complex cognitive
strategies. There is nothing magical about how clarifying questions are
phrased. All of the cautions mentioned in the chapter about questions in gen¬
eral apply here; thus, it may be useful for the reader to reread Chapter Five at
this time. Perhaps the most important rule of thumb, and the only one that will
be reiterated here, is the rule about avoiding “why” questions whenever pos¬
sible. There may be times when a “why” question is appropriate. For the most
part, however, clients will be less defensive and less likely to feel judged if al¬
ternative phrasing is chosen. Beyond that, clarifying questions can take just
about any form as long as they avoid the pitfalls mentioned in Chapter Five
(suggestive, assumptive, pseudo, judgmental, attacking, controlling, intrusive,
tangential, content-diverse multiple, and shotgun questions).
The example that follows uses clarifying questions to build upon the ex¬
ample piovided in the Pointing Out Pcittovns section above. The continuation
of the transci ipt, fiom a later session with the same client, will show how care¬
ful, clarifying questioning can be used to help clients recognize that patterns
often coexist. For example, a habitual way of relating may actually be accom¬
panied by a core belief about people. What may initially have looked like a
single pattern thus evolves into a complex fabric of patterns that interrelate
and maintain each other. As clients become aware of one, they often become
more conscious of the others. Similarly, as one pattern is abandoned, others
will drop away as well. The example shows that clients may be aware of certain
patterns within themselves without understanding why they occur. Careful
questioning can guide the client toward recognizing some of the contributing
factors. Sometimes when they are helped to realize through questions that
there is a second, perhaps more subtle and underlying, pattern, they suddenly
understand the more obvious one (that is, gain some insight, not just aware¬
ness) and begin to move toward behavior change.
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 243

CLIENT: So it happened again this week. I screamed at my boss again.

Now, she had told me if this happened one more time I’d be fired. But
she didn’t do it. God, I’m glad she forgot she said that!
CLINICIAN: How did it come about?
CLIENT: I don’t know. Before I knew it, I was yelling. I do that a lot and I
really cannot for the life of me figure out why it happens. It’s like some¬
thing snaps and there I go. I really have been trying to figure it out. You
know, you and I have talked about this yelling thing so many times now.
Ever since you pointed it out to me I have been noticing it more and
more. You were absolutely right—I yell all the time. I yell at my kids, I
yell at people when I’m driving, I yell at my ex-wife—of course that one’s
normal, isn’t it? (grins at his own joke) So what’s it all about, doc?
clinician: My guess is you don’t always yell. So how about we start by
looking at when you do and when you don’t?
CLIENT: I yell with my lads, I yell with my boss, I yell with everyone. I
do always yell. . . .
CLINICIAN: You’re not yelling now. . . .
CLIENT: Oh . . .
CLINICIAN: What else can you tell me about when you yelled at your
boss this time?
CLIENT: Well, we were working on a project that’s due next Monday and
she got a phone call. She took a long time and I just kept working. Then
she came back and somehow we got into it. It just happened just like
that.
CLINICIAN: Okay now. Here is a question. I remember you telling me
about yelling at Terry last week. Can you remind me. . . .
CLIENT: (client interrupts) Yeah, he had come into my room while I was
working on the cabinet I’m making for my parents for their anniversary
next month. I’m kind of behind on the work. Anyway, Terry came in and
wanted me to take him to the movie theater. Now I had told him earlier
in the day that there was no extra time in my day and that he needed to
get one of his friend’s parents to take them. Well, anyway it just all came
out in a big screaming match.
CLINICIAN: And the time you told me about when you yelled at Jamie . . .

CLIENT: (client interrupts) Oh, two weeks ago? Well, she was supposed
to pick up the kids at three, like every Saturday. Well, she showed up at
four, and I was pissed because I was supposed to be at work, the other
job, you know, by four. So she made me late again! Thats just her irre¬
sponsibility. She was like that when we were married so why would I
think it would be any different now?
clinician: (not allowing the derailment) Now I also remember some

kind of shouting match recently with your mother?

CLIENT: Uh huh. Boy, that’s a while ago now. I don’t remember much of
 244 CHAPTER EIGHT

the specifics. I just know that I was really pressed for time because . . .
(stops suddenly) Oh shit!
CLINICIAN: Yes?
CLIENT: I just got it. Did you know all along?
clinician: No, I only just put it together today too. . . .
CLIENT: (client interrupts) I don’t yell all the time. I yell when I’m
stressed out.
clinician: When your mind tells you you don’t have time . . .
CLIENT: Right!
clinician: So the pattern is really about you telling yourself you don’t
have time . . .
CLIENT: Well, but then I really don’t. . .
clinician: Let’s look at that, I guess. Do you ever feel like you don’t
have time and don’t yell?
CLIENT: Yeah. I feel pressed for time right now. You know, I got lots of
stuff to finish up today and being here makes me short of time.
CLINICIAN: But you’re not yelling . . .
client: No because I figure somehow it’ll all get done. It always does.
clinician: So what’s different, between right now and those times when
you do yell? (moving into using clarifying [that is, has some idea where
this might lead] or open-ended [that is, is not entirely certain of the path]
questions for here-and-now processing)
CLIENT: I m not sure. I guess that’s the million-dollar question, (grins)
For some reason right now I can tell myself “yes, it will all get done,” but
the other times I just can’t seem to do that.
clinician: So what makes the difference? What are you aware of right
now, that helps you say “it will get done”? (using open-ended questions
now to explore here-and-now process; that is, no longer is sure about
where the client’s answers will lead) (Session continues from there.)

This example shows how clients can be led to recognize their own patterns
through skillful questioning. It also demonstrates that to recognize patterns,
especially patterns within patterns, clinicians have to have a good memory for
detail. It was only because the clinician suddenly remembered that all ex¬
amples of yelling also contained some form of time pressure that she could
guide the client in the right direction. The pattern that ultimately became the
focus of the session was that of time pressure. In the prior session, it had been
the pattern of yelling, a more obvious and perhaps destructive pattern. The
recognition that a cognitive pattern underlay the behavioral patterns led to an
exploration of the cognitive pattern. Once the client recognized the meaning
of the self-imposed time pressures and other cognitive patterns that went along
with it, he became increasingly self-aware and ultimately able to change his
overt behavior.
 WORKING WITH THOUGHT AND COGNITION: OVERVIEW 245

Skill Development Recommendations

Recommendation 8-1 Pick a topic area that you think will he likely to
come up with the clientele with which you anticipate working (for example,
sexually transmitted disease or birth control if working with adolescents, or
disease prevention if working with aging adults). Check the popular media
and the scientific literature about this topic and write down what you learned
from each. What did you learn that was new? What did you learn that sur¬
prised you? Was the information derived from scientific sources different
from that in the media? Was the information you had about the topic before
you did this search fact-based or opinion-based?

Recommendation 8-2 Pick a possible new label (as you would in refram-
ing)for the following adjectives that are commonly used by clients. Your new
label needs to represent a shift in perspective that would be derived from new
facts or new ways of looking at old data.

Examples: meddling concerned

intrusive protective
passive laid-back
Reframe: uninvolved
controlling
interfering
rigid
unprincipled
overemotional
cold
unfeeling
angry
careless
scattered
thoughtless
heartless
distant

Recommendation 8-3 To train yourself to detect patterns, begin to look

for patterns in yourself, your friends, and your family members. Pay atten¬
tion to patterns in behavior, thought, affect, and relationships. As you detect
patterns, attempt to determine how and why they may have developed, what
function they used to serve, and how they are working right now.
246 CHAPTER EIGHT

Just to reiterate, although this example focused on pointing out a pattern,

clarifying questions can be used not only to point out patterns. They also can
be used to help clients arrive at virtually any conclusion or point the clinician
had already reached. Thus, clarifying questions are often also used in conjunc¬
tion with more advanced cognitive techniques. The alert reader will find many
clarifying questions in the examples in the next chapter. It might be useful
(though somewhat nitpicky) to note that sometimes the mental-health-care
provider will not know exactly where the client will end up in exploring a par¬
ticular contradiction, here-and-now event, or potential explanation of behavior,
affect, thought, or interaction. In such cases, questions that are asked may bet¬
ter be labeled open-ended rather than clarifying.
Working
with Thought
and Cognition

Advanced Interventions

Interpretation is dependent upon the circumstances in

which it occurs. ... A strategy for finding a context may
be essential to all interpretation as a condition for the
very possibility of interpretation.
D. Hoy, 1978, pp. 69, 76

The strategies presented in this chapter, namely confrontation, here-and-now

process, and interpretation, are perhaps some of the most difficult interven¬
tions clinicians will use with clients. They are best not overused and certainly
always need to be used in a larger context of thorough understanding, solid rap¬
port, and profound caring. Since these strategies can be perceived by clients as
more confrontational than the interventions presented thus far, they need to
be used with skill and presented with caring. Establishing a context is critical
for the optimal use of these strategies, especially for interpretation, but also for
here-and-now process and confrontation. Of the three strategies, confrontation
is easiest to learn and apply. Here-and-now process is the one most frequently
used and most powerfully effective (at least usually). Interpretation tends to be
one of the most overused strategies. It can be profoundly helpful when prop¬
erly timed, and profoundly ineffective, even hurtful, if poorly timed or forced
onto a client. When in doubt about the usefulness or timing of an interpreta¬
tion, it is best not to use it.
The establishment of a context is the most difficult aspect of the use of these
three advanced strategies. The application or implementation of the strategies
proper is easy. The mechanics are simple and straightforward and not much dif¬
ferent from those for other, simpler strategies. The establishment of a context
is largely dependent upon a clinicians theoretical framework for conceptualiz¬
ing clients’ lives and presenting concerns. Any advanced cognitive intervention
will reflect the clinicians preferred way of thinking about human behavior. Two
hypothetical clinicians, working with the same hypothetical client, may both
decide to intervene with the same strategy (for example, both may decide an
247
 248 CHAPTER NINE

interpretation is in order). They will use the same or similar mechanics, but the
content of what they are ultimately going to communicate to the client will dif¬
fer according to their chosen theoretical orientation. For example, a cognitive be-
haviorist will use interpretations just as much or as often as a psychodynamically-
oriented therapist (although the common perception is that interpretation is
largely used by those who adhere to psychodynamic or psychoanalytic schools
of thought). However, the two mental-health-care providers will differ in what
they express in their interpretation. The cognitive behaviorist will focus the in¬
terpretation on learning histories, distorted thought processes, and similar
concepts tied to the conceptualization chosen; the psychodynamic thinker will
focus instead on childhood experience, relationships with parents, and resulting
current transferences or projections. Neither clinician is wrong; neither is ex¬
clusively right. The reality is that there are many ways in which to interpret and
understand human behavior. The most important issue ultimately is whether
the clinician is consistent across time, has tailored the understanding to the
client, does not force a perception on the client, and arrives at an understand¬
ing and explanation that resonates with and rings true to the client.

Establishment of a Context
for Advanced Cognitive Intervention

Clinicians of any school of thought will be able to use confrontations, here-and-

now process, and interpretations as long as they take the time to establish a
proper context and to create an empathically correct understanding of the
client. The nuances of whether cognitive behavioral, humanistic, existential,
psychodynamic, or other jargon is used is much less critical than the issue of
whether the clients understanding is correct and relevant to current experi¬
ence. A responsible clinician will learn about as many conceptualization options
as possible to arrive at a system of understanding clients that will encourage
careful intake and conceptualization procedures. Regardless of the conceptu¬
alization underlying a cognitive intervention, it is best to communicate with the
client without jargon. It is best to translate understandings into everyday lan¬
guage that is accessible for the client and does not dehumanize the client by
being presented in mechanical language. A relatively nontheoretical framework
for thorough assessment and conceptualization work is presented in Brems
(1999) and Cormier and Cormier (1998); an exceptionally detailed and com¬
plex metatheoretical framework has been presented by Wilber (1993). A few
brief guidelines will be suggested here, sufficient for the beginning clinician to
understand what is involved and what still needs to be learned, and to begin to
practice advanced cognitive strategies (that is, confrontation, here-and-now
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 249

process, and interpretation), and perhaps to experiment with a variety of the¬

oretical conceptualizations.
Most simply put, understanding a client is based on at least four steps or
competencies.

1. First, the mental-health-care provider needs to learn as much about hu¬

man nature and different ways of understanding it as possible:
2. Second, the therapist needs to develop a clinical procedure for establish¬
ing a detailed fund of information and knowledge about each client.
3. Third, the counselor uses the fund of information established about the
client and the familiarity with numerous schools of thought about human
behavior to arrive at a careful conceptualization that is tailored to and
recognizes all of the clients specific circumstances.
4. Fourth, the clinician keeps the conceptualization of each individual client
in mind during all work with that person and uses all strategies within the
context of that understanding to keep interventions experience-near for
the client.

Step One Toward Building Context

The first step toward competency minimally requires that clinicians become fa¬
miliar with the most commonly used theoretical schools of thought. Mental-
health-care providers need to read about and gain a thorough understanding of
the basic underlying principles and conceptualizations espoused by psycho¬
dynamic/psychoanalytic theory, humanism, existentialism, cognitive behavioral
theory, rational emotive theory, behaviorism, learning theory/social-learning
theory and modeling, systems theory, and perhaps transpersonal psychology.
Suggested resources for this process follow.

Primary References:
. Analytical psychology: Its theory and practice. (Jung, 1968)
. Casebook of multimodal therapy. (Lazarus, 1985)
• Cognitive therapy: Basics and beyond. (Beck, 1995)
• Ericksonian methods: The essence of the story. (Zeig, 1994)
• Family therapy techniques. (Minuchin and Fishman, 1981)
• Flash of insight: Metaphor and narrative in therapy. (Pearce, 1996)
• Focusing. (Gendlin, 1981)
. Gestalt therapy integrated. (Polster and Polster, 1973)
. Gestalt therapy verbatim. (Peris, 1969)
• How does analysis cureP (Kohut, 1984)
. International handbook of behavior modification and therapy. (Beliak,
Herson, and Kazdin, 1990)
• Interpersonal process in psychotherapy: A relational approach.
(Teyber, 1997)
 250 CHAPTER NINE

• On becoming a person. (Rogers, 1961)

• Paradoxical psychotherapy. (Weeks and L’Abate, 1982)
• Process experiential psychotherapy. (Greenberg, 1994)
• Psychosynthesis. (Assaglioli, 1965)
• The practice and theory of individual psychology. (Adler, 1969)
• The practice of multimodal therapy. (Lazarus, 1981)
• The practice of rational-emotive therapy (RET). (Ellis and Dryden, 1987)
• The structure of magic (Volumes I and II). (Bandler and Grinder, 1975)
• The will to meaning: Foundations and applications of logotherapy.
(Frankl, 1969)
• Treating the self: Elements of clinical self psychology. (Wolf, 1988)
• Toward a psychology of being. (Maslow, 1968)
• Zen and the heart of psychotherapy. (Rosenbaum, 1999)

Secondary References:
• Counseling psychology. (Gelso and Fretz, 1992)
• Current psychotherapies. (Corsini and Wedding, 1997)
• Foundations of clinical and counseling psychology. (Todd and Bohart,
1994).
• Introduction to therapeutic counseling. (Kottler and Brown, 1992)
• Personality theory and psychopathology. (Rychlak, 1984)

Although most clinicians will ultimately develop a preference for one or

two schools of thought over the others, it is important to recognize that it is the
client and the client s presentation that should determine the conceptualization
of the case. Thus, for some clients the clinicians usually preferred school of
thought may fall short; the responsible counselor will seek alternative explana¬
tions and understandings. Learning about different schools of thought does not
mean committing to one and then forcing all clients to fit into that mold. It
means learning to understand which school of thought and which strategies fit
best for which client and then working out of that model consistently and em-
pathically with that particular client. Thus, knowing many ways of conceptual¬
izing client behavior is crucial to responsible mental-health work as it will pre¬
vent forcing clients into a mold. Rogers’ adage that “if the clinician only has a
hammer, all problems will look like a nail” has perfect applicability here. The
clinician needs as many tools as possible to respond flexibly and adaptivelv to
the unique presentation and development of each and every client. The ability
to apply a particular way of thinking about human behavior and to recognize
which understanding is most appropriate for a given client requires cognitive
flexibility on the part of the clinician as well as creative thought, the ability to
think outside of a box, and sufficient information about the client to work with
confidence and clarity.
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 251

Step Two Toward Building Context

Not surprisingly then, the second step toward establishing competency in cre¬
ating a proper context for advanced cognitive work minimally requires the de¬
velopment of a thorough intake procedure based on systematic inquiry to build
an adequate data base about the client. Optimally, the intake interview would
be supplemented as needed by additional special assessments centered around
special issues such as substance use, medical interface, mental status, complex
psychological symptomatology, and crisis issues (for example, suicide or vio¬
lence). This thoroughness in data collection will ascertain that the mental-
health-care provider has collected sufficient information to understand the cli¬
ent s workings and to conceptualize the client’s life and presenting concern as
accurately as possible. Review of Table 5-4—data to be collected in an intake
interview—in this new context may help counselors absorb the information in
a new light. The intake is not just a tedious process imposed on the client for an
arbitrary purpose, but is actually the basic building block of all therapeutic work
that is to follow. If therapists do not collect thorough intake data, their concep¬
tualizations will likely reflect their personal beliefs about how humans develop
and behave in general, rather than reflecting the specific realities and circum¬
stances of that particular client. It is when intake data are incomplete that the
clinician works only with a “hammer” and every client becomes a “nail.” The
more data the clinician has available about the given client, the more likely that
the client will be recognized and appreciated as a complex human being with a
complex and detailed history that makes the client much more than a simple
nail that can be fixed by a simple stroke of a hammer. The clinician will make
use of a much larger toolbox, selecting the specific tool that is appropriate to
the clients specific concern and its etiology or background.
For example, two clients may present with the same symptoms of depres¬
sion; both have difficulty sleeping, decreased experience of pleasure in activi¬
ties they used to enjoy, loss of appetite and weight, difficulty rousing themselves
in the morning, and a tendency toward withdrawal from social interaction. It
would be easy for clinicians to look at the two clients and to decide that they will
benefit from the same treatment plan given their very similar presentation of
pathology. However, thorough data collection may reveal that these two clients
have very different life circumstances, both current and past, and actually have
two very different types of depression despite their similar symptoms. One
client may come from a deprived childhood home that never facilitated the de¬
velopment of a healthy, vigorous self upon which the client could draw during
times of stress. This client has always been vulnerable to depression and has a
personality style that reflects a basic insecurity and fragmentation that derives
from the uncertainty experienced by the client in the family of origin during
the clients shaping early years. The other client, however, may come from a
psychologically nurturing home and may experience a depression that is not tied
 252 CHAPTER NINE

to a basic vulnerability in self development but to an existential recognition of

life’s finality and personal mortality. Perhaps this client was recently confronted
with life-and-death issues due to a close family members death or due to a per¬
sonal medical crisis. The same symptoms may be presented but for a vastly dif¬
ferent reason and superimposed on a vastly different personality structure. Only
sufficient data collection will help the clinician recognize the profound differ¬
ences in the meaning of the client’s symptoms and the nature of the depression.
Had the clients’ childhoods not been explored, the clinician would not have
been able to discern that one client has a vulnerable self while the other has a
healthy self; had the clients’ current life circumstances not been explored, the
clinician would not have been able to discern that for one client existential is¬
sues play a role while for the other client much more basic issue were the crux
of the presentation. Only thorough data collection prevents the clinician from
making generalizations about symptoms and their development.
Thoroughness in intake interviewing sometimes goes even beyond the
data suggested for collection in Table 5-4. Occasionally clients will present with
special circumstances that beg for more information. Such circumstances in¬
clude presentations that suggest the involvement of substance use, medical is¬
sues, violence, suicide, and similar crisis states. Assessment will have to be ex¬
panded accordingly and often exponentially to achieve a complete and accurate
picture of such clients. Assessments necessary for special challenges are de¬
tailed in Brems (2000). Their discussion is beyond the scope of this book. An
example, however, will suffice to point to their importance. It is possible that a
third client will present with yet again the same depressive symptoms outlined
above. In this case the therapist recognizes the need for questions regarding
medical and substance use involvement. This additional data collection leads to
the discovery that the client may actually suffer from hypothyroidism, a physical
disorder that often presents with depressive symptomatology. Although psycho¬
therapy or counseling may be profoundly helpful for the client for many reasons,
the depression would never be resolved without the recognition of the physi¬
cal involvement and appropriate medical treatment. The use of the most pro¬
found and well-meaning affective and cognitive strategies would fall short of
helping this client combat a depression that is physiologically-based. A skilled
counselor will have asked enough additional questions to have recognized the
need lor a medical referral and, thus, will have laid the groundwork for the next
step in this process of establishing a context, namely, accurate and relevant con¬
ceptualization and treatment planning.

Step Three Toward Building Context

The third step toward competency is that of accurate conceptualization and
treatment planning. Clearly, this step is impossible without the second step,
that is, without the collection of unbiased and detailed data about the client.
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 253

Once the data have been collected, they are collated in a manner that can be
used to arrive at an understanding of the client based upon the clients unique
life experience, biology, culture, and all other data points at hand. Such a con¬
ceptualization pays careful attention to the possible predisposing, precipitat¬
ing, and perpetuating factors that are functioning in the clients life and that
contribute to or explain the client s current presentation. It outlines the dynam¬
ics of the case, detailing intrapsychic factors, interpersonal matrix, and family-
related dynamics that appear to relate to the clients presenting concern and
way of being in the world. The conceptualization is not complete until it ac¬
counts for most if not all problems, behaviors, cognitions, and affects presented
by the client (Weiss, 1993). It considers the context for each presenting prob¬
lem, integrating all apparently separate parts of the client into one cohesive
and holistic network of events and experiences that can explain even apparent
inconsistencies or contradictions (Karoly, 1993). A good conceptualization
is free of biases or stereotypes, keeping all attributions logical and rational
(Olson, Jackson, and Nelson, 1997). In the words of Basch (1980), “A therapist
should not make a [conceptualization] simply on the basis of the main com¬
plaint, nor should he [sic] center on a patients symptom. The therapist should
consider the context in which the complaint is made or in which the symp¬
tom occurs, for it is the context that often leads to an understanding of what
is going on with the patient and of what needs to be done for him” (Basch,
1980, p. 121).
Dealing with case conceptualization in detail is beyond the scope of this
book. The complexity of this issue is underscored by the fact that whole books
have been written about this very topic (for example, Berman, 1997; Eells,
1997). However, understanding the purpose of a conceptualization will greatly
enhance the clinicians ability to develop one. Hence, some of the preliminary
and core questions that need to be answered through the conceptualization are
offered here. If the clinician can answer most or all of these questions, therapy
or counseling is possible and the use of advanced cognitive strategies is indi¬
cated and potentially successful.

Preliminary Questions to Be Answered

by a Case Conceptualization
. How did the clients thoughts, expectations, beliefs, affects, behaviors,
and relationship patterns develop over the life span?
. What is the purpose served by the clients thoughts, expectations, beliefs,
affects, behaviors, and relationship patterns in different situations, cir¬
cumstances, and relationships?
. How do the clients thoughts, expectations, beliefs, affects, behaviors, and
relationship patterns manifest in current relationships?
• How did the clients thoughts, expectations, beliefs, affects, behaviors,
and relationship patterns manifest and solidify in past relationships?
254 CHAPTER NINE

• What is or was the potential or past adaptive value of the client s thoughts,
expectations, beliefs, affects, behaviors, and relationship patterns?
• What benefits in general does the client derive from her or his thoughts,
expectations, beliefs, affects, behaviors, and relationship patterns?
• What benefits does the client derive from her or his thoughts, expecta¬
tions, beliefs, affects, behaviors, and relationship patterns in particular
situations, circumstances, or relationships?
• What are the negative consequences in general of the clients thoughts,
expectations, beliefs, affects, behaviors, and relationship patterns?
• What are the negative consequences in particular situations, circum¬
stances, or relationships of the clients thoughts, expectations, beliefs,
affects, behaviors, and relationship patterns?
• What are the coping patterns or styles that result from the client s
thoughts, expectations, beliefs, affects, behaviors, and relationship
patterns?
• What are the coping failures that result from die clients thoughts, expec¬
tations, beliefs, affects, behaviors, and relationship patterns?
• What types of expressed and unexpressed needs result from the cfient s
thoughts, expectations, beliefs, affects, behaviors, and relationship
patterns?
• What kinds of conflicts (both intrapsychic and interpersonal) have re¬
sulted or may result from the clients thoughts, expectations, beliefs,
affects, behaviors, and relationship patterns?

Core Questions to Be Answered by a Case Conceptualization

• Given the answers to the preliminary questions, how are the client s
presenting concerns best understood in terms of their development,
purpose, and past and current manifestation?
• Given the answers to the preliminary questions, how are the clients other
symptoms (not presented by the cfient as problematic but identified by
the clinician) best understood in terms of their development, purpose,
and manifestation?
• Given the answers to the preliminary questions, what has predisposed
the cfient for her or his presenting concerns and other symptoms?
• Given the answers to the preliminary questions, what has precipitated
the development of the cfient s presenting concerns and other symptoms?
• Given the answers to the preliminary questions, what factors in the cli¬
ent s life are perpetuating the existence of the client’s presenting concerns
and other symptoms?

A conceptualization that can answer most, if not all, of these preliminary

and core questions provides a more-than-adequate foundation from which to
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 255

begin therapeutic work with a client. A conceptualization of this nature must

be clearly differentiated from a diagnosis; the terms diagnosis and conceptual¬
ization must not be used interchangeably, though many writers unfortunately
continue to do so. A conceptualization is much broader than a diagnosis. A diag¬
nosis looks at a client s symptoms and then arrives at a label that will be used to
classify the client s behavior within a particular diagnostic category,, using some
form of diagnostic categorization (such as the DSM-IV [American Psychiatric
Association, 1994]). A conceptualization, on the other hand, looks at why,
when, with whom, and how a client’s presenting concern developed and man¬
ifests and is not concerned with how best to label the client (also see Brems,
1999). Diagnosis does not lead to treatment planning; conceptualization does.
Conceptualization is a necessary prerequisite for the determination of an indi¬
vidual treatment plan. The development of a treatment plan is a process, not a
single static decision, and it is highly contextual and flexible. It results in
choices regarding desirable treatment goals and outcomes, as well as decisions
about how to achieve these end states. This how-to translates into choices of
strategies and interventions and is directly related to and relevant for the next
step in context development.

Step Four Toward Building Context

The fourth step in competent therapeutic work requires translating the correct
understanding of the client into content that permeates the strategies that will
be chosen from here on out. In other words, once clinicians have arrived at a de¬
tailed and accurate conceptualization of a clients presentation, they are ready
to begin treatment, using interventions that move beyond simple communica¬
tion-facilitating work. All their interventions, but especially advanced cognitive
interventions, will reflect the clinician’s understanding of the client’s thoughts,
affects, behaviors, relationships, and presenting concerns. Thus, if the concep¬
tualization was inadequate (if the client is viewed as a nail because the clinician
only brought a hammer), even the most skilled application of confrontation,
here-and-now process, and interpretation will fail because it will be perceived
by the client as unempathic, off-target, and experience-distant. This lack of res¬
onance and perceived acceptance will lead the client to feel misunderstood and
may result in premature termination or dissatisfaction (rightly so) with the
counselor or therapist. All strategies have to be used for a reason and the rea¬
son has to be based in an accurate understanding (conceptualization) of the
client. Inaccuracy in the clinicians understanding of the client will be most
harmfully evident in the application of advanced cognitive strategies, as these
strategies are aimed toward helping clients gain an understanding of their
symptoms and lives. If the counselors conceptualization is incorrect, this mis¬
understanding will be communicated to (or even forced upon) the client
256 CHAPTER NINE

through interpretations or here-and-now process comments. Because the in¬

terventions reflect misunderstandings, they will fail to resonate with the client,
and at best will be rejected, at worst will be used by the client as evidence that
truly no one, not even the therapist, can understand. Correct, well-timed con¬
ceptualization, on the other hand, will lead to interpretations and process com¬
ments that will resonate with the client and can lead to self-acceptance, insight,
and perhaps even attitude or behavior change.
In summary, the establishment of a context is critical for all therapeutic
work but most importantly so for the application of advanced cognitive strate¬
gies. Interpretations and process comments will be accepted and usefully ap¬
plied by the client if they are based in accurate understanding or conceptual¬
ization of the clients life and presenting concerns; they will be perceived as
intrusive and unempathic if they are based in stereotypes, prejudgments, and
inaccurate conclusions about insufficient data. Context cannot be ignored in
advanced cognitive work; in fact, context is everything. Without accurate con¬
text, advanced cognitive work can literally hinder therapeutic progress regard¬
less of how well-meaning and caring the clinician who applies it. Not surpris¬
ingly, advanced cognitive strategies are not often used early in treatment; they
are reserved for later points in treatment when the mental-health-care pro¬
vider has developed sufficient data (context) to understand (conceptualize) the
client accurately. If used late and sparingly, they can be profoundly effective; if
used early and often, they can engender defensiveness and rejection by the
client.

Confrontation

Confrontation is a strategy, or rather a process, that is used purposefully to

point out an incongruence, discrepancy, inconsistency, or mixed message of a
client that the clinician understands to have a meaning, impact, or purpose in
the clients life. The purpose of this pointing out is not to attack, humiliate, or
challenge the client, but to increase self-awareness and understanding, and
consequently motivation for change. Despite the label and colloquial under¬
standing of the term, confrontation does not imply a harsh challenge or attack
on the client. Its purpose is not to move against or provoke the client, but rather
to clarify something about the client that seems to be contradictory or incon¬
gruous. Confrontations are neither aggressive nor hostile but are actually de¬
livered in a gentle and caring manner (Ivey, Ivey, and Simek-Morgan, 1997).
Clearly, a therapist has to be able to identify incongruence, discrepancy, incon¬
sistency, and mixed messages to use this strategy effectively. It is best to learn
to be aware of issues ripe for confrontation by paying attention to consistencies
(or lack thereof) in clients’ behaviors, attitudes, emotions, relationships, and
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 257

Categories and Examples of Client Inconsistencies

and Discrepancies

Category Example

Behavior versus feeling Client claims not to be frightened of peers but evi¬
dences behavioral signs, such as nervous tics or
fidgeting, when talking about or exposed to them
Behavior versus thought/attitude Client talks about the importance of respecting and
valuing a spouse and not believing in divorce, but en¬
gages in domestic violence
Actual behavior versus talked- Client claims to be a patient and tolerant parent, but
about behavior when observed with children reacts with annoyance,
anger, and impatience
Behavior in one setting versus Client behaves withdrawn and shy in social settings
behavior in another setting with strangers, but outgoing and exuberant in a small
circle of close friends
Behavior with one individual Client is subservient and passive with authority figures
versus behavior with another but aggressive and demanding with people in equal or
individual subordinate positions
Feeling versus thought/attitude Client is tearful and despondent about the loss of a
relationship but claims an attitude of indifference about
the person who left
Actual feeling versus talked- Client talks about feeling frightened and upset about
about feeling trouble at work, but outward signs of emotion convey
aggression, rage, and anger
Feeling in one setting versus Client is anxious and panicky when home alone, but
feeling in another setting feels confident, safe, and strong while at work
Feeling with one individual Client evidences symptoms of depression with spouse,
versus feeling with another but is happy and relaxed around friends
individual
Thought/attitude in one setting Client expresses optimism and goal-directed thought
versus thought/attitude in at work, but has black-or-white thinking and a skeptical
another setting attitude in intimate relationships
Thought/attitude with one Client jumps to conclusions and makes prejudgments
individual versus thought/ when with parents, but is open-minded and flexible
attitude with another individual when with friends

verbalizations across settings and modalities. Some examples of possible in¬

congruence are shown in Table 9-1. The list is no doubt woefully incomplete,
but should give the reader an idea of what to look for. Most simply put, dis¬
crepancies and inconsistencies can occur across thoughts, behaviors or rela¬
tional patterns, and feelings; in terms of what is expressed (nonverbal) versus
claimed (verbal), in terms of what occurs in one setting versus another, and in
terms of what occurs with one set of individuals versus another.
258 CHAPTER NINE

Basic Mechanics of How to Use Confrontation

One very common inconsistency, expressed by almost all clients, is that they
come to therapy or counseling asking for assistance with behavior, attitudinal,
or affective change but then evidence strong resistance to new ways of being,
feeling, or thinking. This apparent contradiction has many explanations. Often
symptoms developed for a specific reason and at least at one time in the client s
life served a particular purpose or function. Giving up the symptom therefore
means relinquishing its function and finding a new behavior, thought, or emo¬
tion to replace it. This is a very difficult process, as the client in the meantime will
feel vulnerable and unprotected. Understanding symptoms as self-protective
mechanisms and not focusing treatment solely on the letting-go of symptoms
can help the clinician be more empathic and the client more open to change. The
same process tends to be true for all inconsistencies and discrepancies. Some
reason or purpose exists for the discrepancy. How the clinician understands that
reason or purpose will be guided by the theoretical orientation to which the
mental-health-care provider subscribes. However, the commonality across all
schools of thought is the importance of understanding discrepancies before
pointing them out. In this way, the confrontation will not be delivered as a chal¬
lenge, but in a context of empathic understanding and caring. When engaging
in the confrontation the clinician will not address its purpose, but will merely
help the client recognize the inconsistency. Once the inconsistency is noted
and accepted as real by the client, an exploration can begin of how it developed
or came about. This exploration will lead the client toward recognition of the
role or purpose of the discrepancy, an insight-creating process that needs to
precede change. Thus, confrontation as conceptualized here has four steps.

Step One: The clinician points out a discrepancy of the client in a caring
and empathic manner, being straightforward and not challenging the
client.
Step Two: The client and clinician explore the discrepancy together,
helping the client recognize and accept the reality of the discrepancy
or incongruence.
Step Three: The clinician then helps the client explore how the in¬
congruence or inconsistency developed, what purpose it served at
the time of its development, and the impact it has on the client’s
current life.
Step Four: The client recognizes the meaning and impact of the incon¬
sistency and makes a conscious choice about whether the purpose or
impact of the inconsistency has an importance or consequences that
justify maintaining the incongruence in the clients life. If the decision
is yes, there will be no change; if the decision is no, change (in behav¬
ior, thought, or affect) will ensue.
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 259

Some practitioners consider a confrontation complete after the first step of

this four-step process, perceiving a confrontation as a strategy, not a process.
Such clinicians view confrontation as the task of pointing out an inconsistency
or discrepancy without using this as a step toward a larger goal, namely, the goal
of creating understanding and change. This use of confrontation as a single-
step strategy appears incomplete and unfortunate, as the client, may never
glean the full potential benefits of the process of confrontation as defined here.
It must be noted, however, that the four steps outlined above may not always
occur immediately or at once. A confrontation may begin in one session with
one or two steps and then may continue to be explored and addressed in sub¬
sequent sessions until all four steps are complete. A complete confrontation is
not a quick and easy process, but a long intervention that requires patience and
the ability to track progress on the part of the clinician. Once a confrontation
has been initiated, the mental-health-care provider must ensure that it is pro¬
cessed to its logical end (that is, to Step Four), even if it takes several sessions
to do so. Just engaging in the first step (that is, pointing out the inconsistency)
and then never following up on it seems less than helpful. It is important to
finish what is started (unless, of course, clinicians recognize that they made an
error and that there was no need for even the first step; this would then be ac¬
knowledged to the client and the matter would be dropped).

Guidelines for the Use of Confrontation

In addition to paying attention to implementing all four steps of a confronta¬
tion, the clinician has a few other concerns that need to be kept in mind when
using this strategy. Following are a few general guidelines of which to be aware
when using confrontation:

• begin confrontations only after understanding their purpose, meaning, or

origin (that is, have a context for them)
• do not confuse therapeutic confrontation with social confrontation; thera¬
peutic confrontation is used to enlighten, not to challenge
• render confrontations (especially the first step) gently and with caring,
within an environment of empathy and concern
. initiate the process of confrontation only when necessary and therapeuti¬
cally indicated
. time confrontation well within sessions (do not initiate the first step at the
end of the session when insufficient time is left to process it and repair
any damage to rapport it may have precipitated)
• time confrontation well over the course of therapy or counseling (do not
initiate the process prematurely, but rather pace it according to rapport)
. use specifics that are as detailed as possible when presenting the first step
of a confrontation, as opposed to being vague and indirect
260 CHAPTER NINE

• initiate the process of confrontation only when certain that the client can
tolerate it psychologically and emotionally
• do not turn the first step of a confrontation into an attack, accusation, or
judgment
• do not present the first step of confrontation with anger or hostility, or
out of defensiveness or personal offense
• do not overuse the process of confrontation; in fact, use it sparingly
• consider embedding the confrontation into Phase Four of the empathic-
skillfulness cycle

Sample Transcript of Confrontation

Following is a transcript of a complete confrontation, that is, a process of con¬
frontation that proceeded through all four stages in a single session (each clearly
marked). This process occurred quickly and easily as the client was already
well-advanced in treatment and had both an inkling of the presence of the in¬
consistency and a curiosity about its reality. Completion of a confrontation in a
single session is common with a simple incongruence or with discrepancies the
client has slowly become aware of and was ready to deal with (as in the example).
Also, the closer a client is to termination (that is, the more insight the client al¬
ready has achieved), the more likely it is that confrontations can be completed
in a single session. Early in counseling, it is much more likely that the process
of confrontation will be spread over multiple sessions.

client: When Tracy said that, I just got flustered, I didn’t know what to
say and so I said nothing. Somehow that seems to happen to me with her.
I’m not sure why. . . .
clinician: You mentioned that it seems to happen with Tracy. . . . Does
that mean you realize that this is somehow unusual and that it doesn’t
happen with others? (Step One in clarifying-question format)
CLIENT: Exactly. I realized that just now. I get flustered with her but that
never happens to me in other relationships with women.
clinician: Does it happen in other relationships, like in relationships
with men?
client: I don’t know why I said it that way. . . . Hmm . . . (thinking out
loud now) Does it happen with anyone else? I don’t remember feeling
that way with anyone else. . . .
CLINICIAN: Ever?
client: Ever! It’s only with Tracy. Hmm . . .
clinician: You said it somehow seems to happen only with her. But has
it always happened with her? (continues Step One and begins Step Two to
determine if it is an inconsistency strictly in feeling and associated behav¬
ior with Tracy versus other persons or across situations)
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 261

CLIENT: Oh, that’s a tough one. It’s been happening for a while now—
but has it always . . . Hmm ... I tend to think, yes, it has. But. . .
CLINICIAN: But?

CLIENT: Well, maybe really early on when I knew her it didn’t. . .

CLINICIAN: Really early on?
CLIENT: Yeah, before we, before I got really serious . . . (long pause;
client clearly thinking deeply)
CLINICIAN: Help me understand.
CLIENT: Well. About six months ago, I had this dream, remember, we
talked about it in here, where Tracy and I were married, and we were
babysitting our grandchildren?
CLINICIAN: Yes, I remember. That was the day when you realized you
really loved her . . .
CLIENT: (interrupts) Yes. Really love her, you know, not like I ever loved
anyone else. Love her like in a way that makes me scared to lose her . . .
So I think that’s when it started . . .
CLINICIAN: That’s when you started getting flustered when she said
things like that?
CLIENT: Yeah, I think so. ... I don’t remember ever running out of
words or being speechless before. It’s like freezing up with fear or some¬
thing. . . . Definitely, that’s it; drat’s when it started.
CLINICIAN: And it never happened with anyone else before? (being thor¬
ough about Step Two)
CLIENT: Right. This is new.
CLINICIAN: So we have two kinds of inconsistencies, or changes. . . .
First, you react differently with Tracy when she says unpleasant things as
compared to when others do. Right?
CLIENT: Right. With other people I can blow it off or it makes me mad
and I get mean. With her I freeze up. . . .
CLINICIAN: And the other thing is that with Tracy it has changed. When
you felt less emotionally close to her, it was easier to react to her like you
do with other people. Right again?
CLIENT: Right. (Step Two is now complete; the discrepancies are estab¬
lished, agreed upon, and accepted by the client.)
CLINICIAN: So what, would you say, made the difference? (beginning
Step Three, exploration of meaning, purpose, or impact)
CLIENT: I guess my own level of feelings about her . . . You know? I was
never that in love before. I always felt like I would be okay if something
happened. Never thought about marriage . . . Didn’t worry about being
without her . . .
CLINICIAN: So some shift happened in you, and it created a change in
how you relate to Tracy versus other people you’ve cared for. . . .
262 CHAPTER NINE

CLIENT: Exactly. She became important to me in a real basic way, like to

my survival almost. Does that sound corny?
clinician: Not at all. Does it sound that way to you?
CLIENT: A little . . . (blushes a little)
CLINICIAN: To me it sounds more like a change in your level of commit¬
ment. . . . Would you say that’s corny?
client: Hmm, I didn’t think of it that way. But that’s it, isn’t it. I want
to commit to her somehow. You know, I bet that’s why people get mar¬
ried, isn’t it? Because they wanna make sure they can have the other
person around for the rest of their lives . . . Kind of selfish in a way . . .
(long pause)
clinician: What are you pondering?
CLIENT: I’m a little shocked by this recognition of feeling committed
and how it’s affecting me. . . . how it’s changing me . . . (another long
pause)
CLINICIAN: How it makes you feel different, or react different (catching
her mistake of shifting from action to feeling) . . . (choosing for now to ex¬
plore the discrepancy, not pursuing the selfishness issue)
CLIENT: Yes. It’s like I’m someone else with her. I guess it’s like I’m so
afraid to lose her that I can’t be myself anymore, like if I’m myself she
won’t like me anymore.
clinician: And being yourself would mean doing what?
CLIENT: Doing what I do with others who say or do something that an¬
noys me—say something, maybe even get nasty, scream, defend myself
somehow, take a stand, for goodness sakes . . .
CLINICIAN: And you’re afraid if you do that with Tracy, she’ll
disappear. . . .
CLIENT: Exactly. And that horrifies me. . . .
clinician: It’s more horrifying to think of losing her than to think of not
being yourself.
CLIENT: Huh?
CLINICIAN: You’d rather not be yourself than face the possibility of los¬
ing her?
CLIENT: That’s kind of what I’m saying, isn’t it. Sounds terrible when you
put it that way, though . . .
CLINICIAN: What sounds terrible about it?
client: Well, some day, maybe I’ll be myself by mistake, you know, out
of habit, and then it’ll be such a big change for her that it really scares her
off. . . or . . .
CLINICIAN: Or?
CLIENT: Or maybe some day I’ll get tired of being flustered and swallow¬
ing my anger . . . Wow!
CLINICIAN: Good point. What about that?
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 263

CLIENT: Well, I guess that would really be a shame. How can I think
about, dream about marriage and kids and grandkids (grins) if I don’t
feel like I’ m me when I’m with her. ... oh boy . . .
CLINICIAN: So it’s in a way a decision you might need to make now.
(moving to Step Four, considering behavior change given the consequences
of the discrepancy) Do you keep up the discrepancy between who you
really are and how you react, and risk losing her now . . .
CLIENT: (interrupts) Or do I start being myself now and see what hap¬
pens before we have grandkids!
CLINICIAN: That about sums it up!
CLIENT: What a dilemma. There are potential costs either way. It’s like a
cost-benefit analysis, isn’t it? Well, I should be able to do this. It’s what I
do at work everyday.
CLINICIAN: Uh huh . . . ? (nonverbal encourager to go on)
CLIENT: It seems pretty clear though, in a way. I mean, how happy will I
be in the long run if I keep feeling flustered and say nothing and later get

pissed off. I mean that’s why I told you about it, right, because I was up¬

set that I did what I did, or didn’t do. . . .

CLINICIAN: (nods; nonverbal encourager to go on)

CLIENT: It’s only a matter of time before I’d explode. And that would be
bad news. Also, she might see me around other people and realize that I
treat her differently, too. That may be weird. Like she’d see a side of me
that she didn’t know before. And she may get disappointed. If I just react
that way I always do now, maybe I won’t overreact. . . and I’ll see how
she responds to a little bit of back talk. I mean we’re not talking about me
screaming or yelling. Okay, sometimes I do, but I don’t think I would. . . .
Well, I guess I sort of have my answer, don’t I? (client worked through
Step Four independently)
CLINICIAN: Sounds like it to me . . . (affirms that Step Four is complete)
CLIENT: Well, I guess I’d better try it next time. . . . Scary, though . . .
CLINICIAN: Oh, I bet it feels scary. And if you don’t do it next time, you’ll
have other chances. The main thing is you’ve realized something and now
it’s just a matter of figuring out how to make a change happen. One step
at a time . . .
CLIENT: True. I’ll probably have lots of opportunities to practice, (grins)

(Session continues from here.)

This transcript demonstrates how all four steps may be accomplished in a

single session with an insightful client who was ready for the confrontation. It
also clearly shows that a confrontation is not an attack or challenge but an op¬
portunity to help clients recognize relational, behavioral, attitudinal, or affec¬
tive patterns or manifestations that are unusual, different, or discrepant in some
way. This can be done gently and caringly, as the transcript shows. The example
264 CHAPTER NINE

Skill Development Recommendations

Recommendation 9-1 Explore inconsistencies in your own life through

journaling or talking to a trusted friend who will give you honest feedback.
Pick one of these inconsistencies and try to figure out its meaning and pur¬
pose. Given its purpose, do you want to change? If so, how might you want
to go about that?

Recommendation 9-2 Begin to learn hoiv to recognize and identify incon¬

sistencies by starting to look for them in others with whom you interact.
Do not do this with close friends or family members f to avoid conflicts).

also serves to highlight that some conceptual notions will enter the confronta¬
tional process, that is, that context will become important and will emerge in a
manner that may differ slightly from clinician to clinician. Not every clinician,
for example, may have framed the clients behavior in terms of level of commit¬
ment. Some counselors may have focused on exploring whether the client ob¬
served a similar pattern in others (for example, parents), or may have focused
on the clients fears of loss. The basic confrontational process, however, stays
the same. All four steps are covered, usually in the order given above, though
sometimes with two steps being worked on simultaneously.

Here-and-Now Cognitive Processing

The importance of a thorough and clear conceptualization multiplies as in¬

creasingly depth-oriented, or insight-oriented, advanced cognitive strategies
are being used. Once the utilization of here-and-now process is being consid¬
ered, therapists need to be very clear about how they conceptualize their cli¬
ents. Counselors at this point will work with clients’ general and developmen¬
tal relational, affective, behavioral, and cognitive patterns as they manifest in
the current (here-and-now) relationship with the clinician. Using here-and-
now processing requires the therapist to understand most, if not all, of the
clients’ patterns, developments, and manifestations of presenting concerns and
symptoms.
The clinicians awareness of how the client behaves, feels, thinks, and relates
and how these functions have developed and play themselves out in terms of
coping ability and need states in the client s current life precedes the clients own
enhanced understanding of these issues. It is not the function of the mental-
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 265

health-care provider to meet a client’s expressed relational, behavioral, cogni¬

tive, and affective needs; it is merely important to recognize, understand, and
accept them. Once this is accomplished, it becomes the task of the clinician to
acknowledge the client s needs empathically to help the client achieve the same
recognition, understanding, and acceptance. There are many ways in which this
therapeutic function can be accomplished (including all cognitive strategies
and the higher-level affective strategies); however, one primary means is the use
of here-and-now cognitive processing, or process comments. Here-and-now
process means using the immediate relationship between client and clinician
to help the client recognize (gain awareness of), understand, and accept needs,
coping styles, symptoms, and expressive patterns.
There are many ways through which the client’s behavioral, affective, cog¬
nitive, and relational patterns (and hence the clients needs, conflicts, coping
style, and so forth) express themselves in the therapeutic relationship. Process
comments are excellent techniques to use whenever such here-and-now man¬
ifestation occurs. What are these ways in which clients’ patterns manifest in the
current relationship with the counselor? Most simply put, here-and-now pro¬
cess is appropriately used whenever an obvious transference or client-specific
countertransference process has occurred or is occurring between client and
clinician. Both transference and countertransference can manifest in as many
ways as there are client and counselor behaviors, thoughts, and feelings. There
is no single way or content that defines all possible here-and-now process situ¬
ations. Clinicians need to be able to recognize transference and countertrans¬
ference to be able to use here-and-now process.
Transference and countertransference are concepts that, although origi¬
nally derived from psychoanalytic theory, have been accepted as real interac¬
tions that occur between clients and their mental-health-care providers by cli¬
nicians of almost all schools of thought. They are processes that acknowledge
that neither clinician nor client react and relate in a vacuum, but rather that
both will relate with the other from a way of relating that was developed over
the lifespan through some form of learning process. Clients rarely just talk
about their problems or concerns when they see a therapist; they also tend to
act them out in the therapeutic relationship. They display and express the same
behaviors, relational patterns, cognitive styles, interpretations, affective reac¬
tions, source feelings, and need states with their clinicians that they display or
use with other human beings and that they learned through interpersonal in¬
teractions over the course of their life span (c£, Brems, 1999; Strupp, 1992;
Teyber, 1997). Counselors are as much a target of ingrained patterns, behaviors,
cognitions, and affective responses as anyone else in a client’s environment.
Similarly, mental-health-care providers are not the blank screen or neutral per¬
son traditional psychoanalysts had hoped for. Such neutrality is impossible given
the reality that clinicians are as human as their clients and hence are reactive
266 CHAPTER NINE

in relationships as well. If clinicians accept the ubiquity of a clients transfer¬

ence, they must also accept the ubiquity of their own countertransference
(Wolf, 1988). The key to success is to use transference and countertransference
productively and not to allow them to get in the way of an empathic therapeu¬
tic relationship. This interpersonal cycle of client expression and therapist re¬
action essentially captures the definition of a transference-countertransference
cycle, or transference relationship, between client and clinician.
A definition of transference as understood here is in order. Given the intense
experiential and relational nature of the therapeutic relationship, it is very likely
that the current here-and-now relationship between client and therapist be¬
comes a stage for ingrained feelings and needs related to the client s past and
current relationships. The recapitulation of the clients behaviors, affects, emo¬
tions, and relational patterns in the relationship with the mental-health-care
provider is the essence of transference. This transference relationship, how¬
ever, is not independent of what the clinician brings to treatment, a definition
of transference that deviates somewhat from traditional psychoanalytic models.
Instead, the current definition of transference asserts that the here-and-now
relationship between client and clinician is always affected by both the client s
transference and the therapists countertransference. This definition of trans¬
ference is entirely compatible with Gill’s (1982) conceptualization of transfer¬
ence as the patients experience of the relationship with the therapist, and
Wolf’s (1988) definition of countertransference as the therapists experience of
the relationship with the client. Both experiences are subjective and flavored
by each individual’s history, background, and current affective and need states.
The client-therapist relationship is an intersubjective relationship that reflects
both the clients and the therapist’s reality (c£, Atwood and Stolorow, 1984;
Natterson, 1991). It is through this relationship to which both client and ther¬
apist contribute knowledge and wisdom that they arrive jointly at a higher and
more accurate understanding of the client (who despite this definition always
remains the sole focus of therapy).
Clients contribute to the transference relationship with the clinician be¬
cause they have grown up in a unique environment with individualized inter¬
personal relationships that influenced their self-development in a manner that
defines how they react emotionally, cognitively, behaviorally, and relationally.
These patterns are not only relied upon in day-to-day relationships, but are also
stimulated and expressed in the here-and-now context of psychotherapy.
Skilled clinicians can facilitate the activation and expression of clients’ needs
and reactions without altering them, in the sense of producing needs or affects
that would not otherwise have been expressed by the client. Skilled counselors
recognize when clients’ affects and needs, however grounded in past relation¬
ships, are stimulated in the here-and-now therapeutic relationship. It is the in¬
spection of the transference relationship that transpires between client and
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 267

therapist at that moment that is the purpose of here-and-now processing. Pro¬

cess comments thus used increase understanding and insight into the clients
development, environment, needs, and directions for change.
Several forms of countertransference were already defined in Chapter
One. Only client-specific countertransference is of issue in this context and will
be briefly revisited. Client-specific countertransference refers to any feeling or
reaction in the clinician that is unique to the work with a particular client. For
example, if a clinician becomes impatient with a client and does not usually feel
this way with other clients, a potential client-specific countertransference ex¬
ists. If the client complains that others tend to react impatiently to the client,
the likelihood of a client-specific countertransference has increased signifi¬
cantly. The clinician can then use this reaction as a springboard for here-and-
now process; a reaction has taken place between client and clinician that re¬
flects a more generic process that die client tends to encounter in life outside
of the therapy room. Process comments thus used become excellent facilitators
of insight and motivators for change and self-recognition (Teyber, 1997).

Basic Mechanics of Here-and-Now Process Comments

Given their basis in a here-and-now transference or countertransference, here-
and-now processing is most commonly initiated through questions or com¬
ments that direct clients’ attention to their reactions in this moment. These
questions or comments draw the client’s attention to a feeling, thought, behav¬
ior, need, conflict, or coping response expressed in the relationship with the
clinician right here and right now. They request that the client pay attention to
a reaction that occurred in the therapeutic relationship. Most often, early in
therapy or counseling, clients are unaware of how they replay patterns in the
therapeutic relationship. As therapy progresses, clients will become increas¬
ingly aware of how they react to the clinician and how this reaction may be rep¬
resentative of their general interpersonal style. As clients become more at¬
tuned to here-and-now process, they will be more and more open to answering
here-and-now process questions and to responding to here-and-now process
comments. Regardless of the client’s initial reluctance about here-and-now
processing, it is a useful strategy that can be used often and liberally, as long as
it is delivered with caring and acceptance. If an initial here-and-now process
comment or question (samples follow) is rejected by a client, it is best to let the
issue drop, especially if rapport is still tenuous. Later in treatment, as rapport
has deepened and the client has made a commitment to counseling, the issue
may be pursued further with follow-up questions as long as the clinician be¬
lieves that the exploration of a here-and-now event will lead to increased un¬
derstanding or insight in the client.
268 CHAPTER NINE

Examples of Initial Process Comments or Questions

• “What are you thinking right now?”
• ‘WTat thought just went through your mind?”
• “What were you just thinking but decided not to say out loud?”
• “Have you had these thoughts in our relationship as well?”
• “Is that what you are thinking right now, too?”
• “How are you feeling right now?”
• “How are you feeling about me right now?”
• “What was that feeling that peeked through just then?”
• “What’s that feeling you are having at the moment?”
• “Have you felt that way with me?”
• “Is that what you are feeling right now, as well?”
• “What did you want to do just then?”
• “What did that movement mean just now?”
• “What’s your body doing right now?”
• “What is your body telling you right now?”
• “Have you wanted to do that in here with me?”
• “What is happening with you right now?”
• “What’s going on with you at this very moment?”
• “What’s going on between us right now?”
• “Is that what’s going on in our relationship right now?”
• “What would you like to say to me right now, but aren’t?”
• “How was our work for you today?”

If questioning is not sufficient to draw out a client’s immediate reaction or

response, the mental-health-care provider may move toward simply pointing
out the observed reaction of the client. Such pointing out of observation may
take many different shapes. A few examples follow. These statements are most
useful when rapport is sufficient to allow the clinician to pursue a here-and-
now exploration even when the client initially rejected a request to do so or
failed to respond to a process comment or question.

Examples of Follow-Up Process Comments or Questions

• “I noticed that you turned away from me. What do you think that’s all
about?”
• “I noticed a flash of feeling in you just then, and you don’t seem to want
to become aware of it.”
. “Your body is saying something to you and you seem not to want to pay
attention.”
• “I heard hesitation in your voice. What might that be about?”
• “I have noticed that reaction in here with me as well. Have you?”
• “There seemed to be some feeling in your voice and then it disappeared.
What happened?”
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 269

' • “Your eyes became teary when I said that. Can we talk about that?”
• "Your tight fists suggest that you are holding something back. What do
you suppose is going on?”
• “You reacted when I said that. Help me understand what went
through you.”
• “You became very quiet after I asked that question. Can you help me
understand what happened?”
• “I noticed you stopped looking at me at that point. What do you think
that may be about?”
• “I can see that you want to say something but instead you seem to try to
keep it in.”

All of these comments and questions focus the client on the present and
on the current relationship or immediate interaction with the clinician. This
immediacy can have a tremendous emotional impact on the client and is a most
powerful therapeutic tool. It draws the client’s attention to an occurrence in the
here-and-now which the clinician believes is of importance in the client’s life
outside of the therapy room. This understanding of here-and-now processing
can accommodate various theoretical frameworks, as it neither implies the spe¬
cific content of the clients expressions, nor the therapists means of under¬
standing or interpreting (explaining) them. For example, a cognitive behavior-
ist may focus on clients’ cognitions (content) and will try to understand their
current manifestation through inspecting their experience in the here-and-now
relationship (understanding) as well as gleaning insight into the development
through learning histories in clients’ lives (interpretation or explanation). Hu¬
manist clinicians will focus on the client’s feelings and self-expressions (con¬
tent) and will look for meaning in the here-and-now relationship (understand¬
ing) while also searching for the origins of feelings and self-expressions in the
family environment and the varying levels of acceptance, genuineness,
warmth, and empathy (interpretation) to be found there. Family systems the¬
orists will explore relational patterns and behaviors (content) and will attempt
to recognize their activation or stimulation in the here-and-now relationship
(understanding), as well as tracing their origins to family interactions, paying
attention to issues such as inappropriate boundaries, triangulation, and so forth
(interpretation).
As was true of confrontations, here-and-now processing does not involve
the implementation of a simple strategy, but rather represents a series of in¬
terventions. Process comments are a multistep process, not a unidirectional,
simple event. They can be part of an empathic-skillfulness cycle (that is, would
be used during Phase Four) or can be presented in their own right. If used out¬
side of an empathic-skillfulness cycle, their steps are as outlined roughly below.
Their order may not always be the same, and several steps may overlap or be
accomplished simultaneously. The final steps, involving exploration of the de-
270 CHAPTER NINE

velopment of a pattern and the creation of change, may not always be accom¬
plished right away but may be therapeutic goals that will be reached at a much
later time. Thus, not all here-and-now comments will lead client and clinician
through all of these steps; the clinician, however, has all of these steps in mind
when initiating here-and-now processing. In that sense, the steps are a kind of
flowchart of what may occur in the mental-health-care provider s mind rather
than a rigid structure imposed upon the client.

An Outline for Processing Here-and-Now Events

• clinicians recognize that a here-and-now event has transpired that reflects
a transference relationship between them and their client; that is, they
recognize an event as representative of how the client reacts with others
outside of therapy
• clinicians gain an understanding of the here-and-now event (or transfer¬
ence expression) in terms of what it communicates about the clients
needs, affects, cognitions, behaviors, and relational patterns in general
• clinicians conceptualize tire here-and-now event in terms of what it com¬
municates about the development of the clients affects, cognitions,
behaviors, and relational patterns
• clinicians gain an understanding of what activated or motivated the cli¬
ent s here-and-now expression and experience of transferential needs,
affects, cognitions, behaviors, and relational patterns
• clinicians tease out their own countertransferences related to the here-
and-now event and recognize when their response is idiosyncratic to
themselves, as opposed to client-specific
• clinicians make a process comment or ask a process question to assess
whether the client is aware of the here-and-now event and the pattern it
may represent
• clinicians help the client recognize the here-and-now event (whether
reflecting emotions, needs, thoughts, behaviors and relational patterns)
as it manifests in the therapeutic relationship
• clinicians help clients recognize how they respond similarly with others in
their environment outside of therapy or counseling
. clinicians may help clients recognize how the pattern played out in the
here-and-now event developed and what purpose it once may have
served, that is, clinicians may help clients understand the here-and-now
event and underlying pattern
• clinicians avoid getting drawn into the emotional valence of the here-and-
now event and thus become able to provide an accepting response that is
different from what the client expects in the here-and-now and/or has
experienced in the past
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 271

• clinicians avoid recapitulating the client’s conflicts or patterns through an

unaware (perhaps countertransferential) response and by accepting the
client’s here-and-now response
• clinicians help the client accept the pattern underlying the here-and-now
event while instilling the motivation for change
• clinicians assist the client with the exploration of alternate responses to
current relationships to break the pattern of response reflected in the
here-and-now event

Recognizing and Utilizing Opportunities for

the Use of Here-and-Now Process Comments
For here-and-now processing to take place, the clinician has to recognize that
a here-and-now event has occurred. If the clinician fails to recognize that a
client has responded to the clinician in a way that is representative of reactions
that manifest in other relationships, it is likely that the interchange will simply
recapitulate a pattern. Recapitulation of patterns usually means that the clini¬
cian responds exactly in the same way to the client as the client expected and
has experienced in other relationships. This often means the recapitulation of
destructive, unhealthy, or negative patterns. For example, a slightly suspicious,
passive-aggressive client may elicit a countertransference in the clinician that
involves anger and impatience. If the clinician is unaware of this emotional re¬
sponse as stemming from the client s behavioral or relational style, she or he may
respond impatiently or angrily, an affect that will be easily recognized by the
client, as this is the very response the client tends to receive from others out¬
side the therapy room, and hence expects. The interaction between clinician
and client becomes similar to any other human interaction the client has expe¬
rienced and serves to strengthen this client s belief in a hostile world. If, on the
other hand, the clinician can recognize that her or his impatience and anger is
a client-specific countertransference, she or he may be able to respond with ac¬
ceptance and understanding. The client will have a different experience in the
therapeutic relationship than in relationships outside of the therapy room and
may recognize that not all human exchanges must involve hostility.
Some clinicians may recognize a here-and-now event, but hesitate to use it
therapeutically. Although they recognize that the client is reenacting with the
clinician a general pattern that emerges in all relationships, this counselor fails
to address the here-and-now event through a process comment. This failure
may occur when a clinician feels uncomfortable with the client s pattern or with
the therapists own countertransferential response. For example, a given female
client may have a highly sexualized way of responding to men. A male clinician
who is uncomfortable with the topic of sexuality may be well aware of how the
client s sexualized pattern of relating is played out in the therapeutic relation¬
ship, but may never address this issue in a here-and-now process comment.
272 CHAPTER NINE

Leaving the client’s mode of relating unexplored will hinder therapeutic prog¬
ress in this regard as she may not be aware that this is how she comes across in
male-female relationships.
Given the potential negative consequences of not seeing here-and-now pat¬
terns or not responding to them if they are recognized, it is important to ex¬
plore factors that may contribute to such blind spots among clinicians. Inability
to recognize or reluctance to address process issues or events can arise for a
number of reasons. First, clinicians may have a personal issue (a countertrans¬
ference based on a trait, issue, or stimulus) that prevents them from recogniz¬
ing the pattern expressed by the client in the therapeutic relationship. For ex¬
ample, clinicians may fail to recognize patterns that are similar to their own or
that elicit a response in the clients communication partner that is similar or
identical to a response style exhibited routinely by the clinician. In either situ¬
ation, the clinician is so involved in the pattern that it becomes invisible or un¬
recognizable. Such a countertransference scenario usually is only resolved
when a supervisor or consultant recognizes how client and clinician encourage
each other in a certain interpersonal style.
Second, clinicians may feel that making process comments is too personal
or emotionally charged. They are reluctant to point out clients’ feelings in the
here-and-now because this process will involve the clinician-client relationship
very directly. The clinician and client will need to work at a level that is usually
highly experience-near for both individuals. Clinicians who have difficulty tol¬
erating affect, interpersonal closeness, or conflict will shrink back from such
therapeutic exchanges and therefore will prefer not to work on the process
dimension.
A third possibility is the clinician’s inexperience with the level of intimate
and open communication involved in here-and-now process. Process comments
are highly unlike anything humans usually do when they communicate with each
other. It makes the unspoken overt and challenges both communication part¬
ners to acknowledge reactions in relation to each other that often remain un¬
spoken. This completely different way of communicating may feel intrusive to
the clinician, not only vis-a-vis the client, but even the self. Clinicians may hes¬
itate to point out here-and-now events they have recognized because they per¬
ceive the intervention as too personal or too unusual compared to their usual
communication style. Relatedly, they may choose not to use a process comment
because they perceive it as potentially offensive or confrontational for the very
reason that it does represent a different mode or level of communication.
A fourth factor that may interfere is clinicians’ fear about not knowing what
to do once the process comment has been made. Especially novice clinicians
worry about what to do once the client acknowledges a feeling or thought
about the clinician. For example, clinicians may be reluctant to point out that
a client experiences anger toward the clinician for fear of unleashing rage
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 273

against the self and not knowing how to stop it. Others may not address sexual
overtones in the relationship because of the discomfort this topic may bring
and because of a lack of knowledge about how to deal with this type of trans¬
ference once it has been pointed out. Process comments often lead to power¬
ful therapeutic interactions, and clinicians may be afraid of not knowing how to
manage the emerging intensity that develops in the relationship with the client.
Rather than unleashing this amount of potential affect or impact, they decide
not to intervene at all.
Occasionally, clinicians may hesitate to make a process comment because
they are not certain if die observation about the here-and-now event is based
in a true transference or client-specific countertransference. In such instances,
reluctance may be appropriate until the clinician has determined whether the
here-and-now event is truly client-related or rather clinician-related. If a here-
and-now event is based on the clinicians trait-, stimulus-, or issue-specific
countertransference, it is clinician-related and does not warrant a process com¬
ment. In fact, a process comment would be inappropriate as treatment is about
the client, not the clinician. If such a here-and-now event occurs, the clinician
needs to explore outside of therapy or counseling why it occurred, what it means,
and how it is best dealt with. Supervision or consultation may be invaluable in
such circumstances.

Sample Transcript of Here-and-Now Process Comments

A generic (theory-free) example of a therapeutic exchange involving here-and-
now processing follows. This transcript will demonstrate a straightforward pro¬
cess comment that was pursued with an insightful client and that managed to
move through several of the steps outlined above. It is worth repeating that not
all here-and-now processing will accomplish everything from identification of
the event to its manifestation in other relationships, development, acceptance,
and change. Clinicians have already accomplished a lot if they can help the
client recognize here-and-now events within the therapeutic relationship.
Helping clients recognize patterns of any sort in the here-and-now will be
highly useful and can be built upon in future sessions even if the client does not
advance through all the steps that clinician can foresee.

CLIENT: I am thinking about breaking up with Mike again. The relation¬

ship is just so complicated and I don’t have the energy to deal with it.
He’s so intense emotionally—I can’t cope with that. He overwhelms me,
really, with all his talk about feelings and getting in touch with feelings,
and expressing emotions, and on and on. It’s just too much. ... I cant
handle that much affect. You know, it wears me out. Feel, feel, feel, feel.
Isn’t it okay sometimes just to do something and not analyze how I feel
about it. My god, even when we go see a movie, we then have to talk
274 CHAPTER NINE

about how we felt about the different characters. He even cries in

movies. I’ve never cried in a movie. Its not real, so what’s the point. (get¬
ting somewhat worked up now) Anyway, I’m thinking about getting out
before he drives me crazy. (calms down)
clinician: It wears you out to talk about feelings?
CLIENT: Oh yeah. Absolutely. It’s a real chore.
clinician: What about it is so hard?
client: It takes a lot of energy, you know. It’s easier to just talk and
have fun.
CLINICIAN: What kind of energy?
client: Oh, emotional energy. You know, energy that draws from my
very inner resources. It’s like it demands something from me I don’t want
to give . . . something very personal. . .
CLINICIAN: Such as?
client: Well, personal parts of me that I don’t want to talk about—how
I really am, who I really am. My innermost self or something. It’s scary. ...
(long pause)
clinician: Your innermost self.. .
client: Yeah, personal stuff, stuff I don’t want to talk about. . . with
anyone!
CLINICIAN: Not with anybody?
client: No! (relinquishes eije contact)
clinician: What’s going on with you right now? (process question)
CLIENT: I don’t know. . . . (withdraws)
CLINICIAN: I can’t help but realize that we talk about feelings a lot,
about that very innermost part of you. . . . (folloiv-up process comment,
leaving the question unspoken for now)
CLIENT: I know .. . (does not volunteer more)
CLINICIAN: Help me understand what’s going on with you right now.
(process comment that acknowledges the clients emotion/reaction into
the here-and-now)
CLIENT: I feel annoyed. Like I wanna break up with you too . . .
CLINICIAN: Just like with Mike. We’re getting too close. . . . (process
comment that ties here-and-now to other relationships)
CLIENT: Yes. It’s like you know everything about me and it scares me.
CLINICIAN: It’s scary right now?

CLIENT: Yes. It’s scary because what if you don’t like my feelings. . .-.
(long pause)
clinician: What if I don’t like your innermost self?
CLIENT: Exactly. Then what?
CLINICIAN: What’s your fear of what I might do?
CLIENT: You won’t like me. You’ll kick me out_(looks up a little)
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 275

CLINICIAN: You’re feeling very vulnerable that if I know your innermost

self and don’t like it, I’ll leave ... or make you leave somehow. . . .
(reflection)
client: Yes. (weepy now)
clinician: And you’re afraid that will happen with Mike? (moving the
here-and-now insight to the larger context of other relationships now)
CLIENT: (cries now) Yes. And then I’ll be alone again. I don’t wanna lose
you. I don’t wanna lose Mike.
CLINICIAN: You’d rather quit therapy or break up with Mike first.
CLIENT: At least then I won’t look so pathetic. . . . (still crying)
CLINICIAN: You said you’d be alone again.
CLIENT: Yes. I always end up alone. All my life people have
disappeared. . . . You know all that. . . . We’ve talked about my parents,
my husband. . . .
CLINICIAN: You’ve lost a lot of people. . . .
CLIENT: Yes . . . (weeping again)
clinician: And you don’t want to lose any more. . . . You don’t want
Mike to leave, you don’t want to lose me. . . .
CLIENT: (nods vehemently, still crying) I couldn’t take it if he left me. . . .
CLINICIAN: You’d rather break up with him first?
CLIENT: (looks up startled) Yes . . . (hesitates) Yes. I guess so . . . (stops
weeping)
CLINICIAN: And you’ve done that before. . . .
CLIENT: Yes. Yes, I have . . . with Jack . . . and George, I guess . . .
CLINICIAN: And Susan and Janet (prior therapists) . . .
CLIENT: Oh my . . . You’re right. It’s a real pattern, isn’t it?
CLINICIAN: (simply nods)
CLIENT: I came here today planning to tell you this was my last
session. . . .
CLINICIAN: I thought you might have. . . .
CLIENT: (smiles sheepishly)
CLINICIAN: We’re getting very close. I know a lot about you; you’ve been
very open with me, and last week we covered some pretty difficult
ground. . . . Scary, huh?
CLIENT: Yes.
CLINICIAN: How are you feeling right now? (simple process question)
CLIENT: Strangely relieved. Like, whew, now I can stay because we got
this out in the open. . . .
CLINICIAN: This?
CLIENT: This scary feeling . . .
CLINICIAN: This vulnerable feeling of being so exposed and then maybe
rejected . . . abandoned . . .
 276 CHAPTER NINE

CLIENT: Yes. You know, because it happened.

CLINICIAN: Yes, it did, or it felt like it did when your parents left you
behind.
CLIENT: How could they do that? (starts crying again) What did I do?
CLINICIAN: Could you have done anything? You were three. . . . (Session
continues from here.)

This transcript shows how subtle a here-and-now event can be. The clini¬
cian immediately realized that the client s complaints about her lover had clear
implications and possible manifestation in the therapeutic relationship, as many
of the noted features were identical (talking about feelings, revealing her in¬
nermost self, escaping from emotional closeness). Thus, the clinician knew im¬
mediately to listen for here-and-now manifestations of the clients relational
pattern of leaving before being abandoned. Once the client gave an opening,
the clinician pursued it and then tied the here-and-now event back to the orig¬
inally discussed relationship as well as further back to the relationships in which
or from which the clients pattern developed. The next step of the process will
entail helping the client accept that this is how she has learned to respond and
that she now has control over changing her behavior to arrive at a new, more
satisfying relational pattern or style. Much here-and-now processing starts the
way this example starts: The client makes comments about others that also ap¬
ply in the therapy setting. This is often a way for clients to communicate diffi¬
cult feelings in the therapeutic relationship without having to confront the cli¬
nician directly. It is important that clinicians learn to pick up these hidden
here-and-now events and to make a process comment that brings them into the
open so that they may be dealt with directly and openly.

Interpretation

Interpretation is the next, and final, logical step in advanced cognitive process¬
ing. As has been noted, it can be part of confrontations and here-and-now pro¬
cess comments, but it is also a strategy in its own right. Interpretation must be
embedded not only in the context of an overall conceptualization, as empha¬
sized for all cognitive strategies, but also in a context of profound caring, rapport,
and empathy. Interpretations are best delivered in a context of Phase Four of
the empathic-skillfulness cycle. Interpretations have many potential shortcom¬
ings and pitfalls and are best used sparingly. They can feel experience-distant
to clients, if delivered abruptly, out of context, intellectually, or quickly. Inter¬
pretation is the cognitive strategy that has the most depth, requires the most
cognitive flexibility of both client and clinician, necessitates the highest level of
rapport and understanding before being used, and is most likely to reflect the
clinicians theoretical orientation. Interpretations establish a meaning for a cli-
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 277

Skill Development Recommendations

Recommendation 9-3 Take a mental time-out in groups and one-on-one

relationships to step back and observe the process. Do this by asking what
is happening right now, trying to analyze the process dimension of a given
interaction.

ent by rendering explanations for presenting symptoms, conflicts, needs, coping

strategies, defenses, affects, thoughts, behaviors, and relational patterns based
on the clients past relationships or experiences. They help clients understand
what has shaped and maintains their current self-experience and reactions by
making meaningful links between current relational patterns and responses to
formative relationships and significant experiences in the past.

Assumptions Underlying the Use of Interpretations

Meaning is established based upon the clinicians way of interpreting or under¬
standing human behavior. Two different clinicians may explain the same client
behavior in slightly different ways, depending on how they tend to conceptual¬
ize human behavior. The difference in the content of their respective interpre¬
tations does not imply that one is right and the other is wrong. In fact, once one
looks beyond the jargon of two clinicians, who claim adherence to two differ¬
ent schools of thought, one often finds remarkable consistency in meaning. On
the surface, however, as far as content and language are concerned, the same
client may receive different explanations for the same behavior. A behaviorist
may explain a clients experience by pointing out reinforcement histories and
cause-and-effect relationships. A cognitive behaviorist will attempt to help the
client recognize and understand the origins of irrational beliefs or automatic
thoughts. A self psychologist will attempt to help the client recognize that em-
pathic failures on the part of caretakers in the past resulted in certain vulnera¬
bilities in the client s self development that have resulted in behavioral patterns
and responses designed to protect these vulnerabilities. Beyond this content,
however, all of these clinicians use interpretations in the same way, often look
back in the client s life to establish meaning, and share three basic assumptions
about interpretations:

1. Current reactions and experiences do not occur unpredictably and co¬

incidentally, but rather are tied to past and/or present experiences, rela¬
tionships, and (social) learning histories that continue to influence and
shape a given clients development, reactions, experiences, or adjustment.
278 CHAPTER NINE

2. Clarification of the developmental history, deeper meaning, and explana¬

tion of past, current, and here-and-now relationships or reactions (af¬
fects, behaviors, thoughts, needs, conflicts, symptoms, and so on) facili¬
tates and motivates change and growth.
3. Explanations to create meaning and clarification of developmental his¬
tory are useful only if they are individualized for each client and do not
follow a patent formula that is forced upon all clients.

The first assumption is truly common to all schools of thought. It would ap¬
pear that there is consensus among psychologists, counselors, social workers,
and other mental-health-care providers that human behavior is shaped in an in¬
terpersonal context during the developmental years and beyond. How clients
were raised and how they grew up in a smaller and larger interpersonal matrix
(ranging from the nuclear family to the extended family to the community, the
social setting, the culture) can often help explain why they behave, feel, and
think the way they do. This knowledge helps clinicians understand why the
client developed certain relational patterns, symptoms, needs, conflicts, and
coping styles and the purposes each served for the client over the life span.
Emphases may vary across schools of thought with regard to the level of im¬
portance of distant-versus-not-so-distant past. But most if not all theorists look
at clients in a temporal context that goes beyond the here-and-now.
The second assumption must be common to all clinicians who use in¬
terpretations, lest the act of choosing interpretations be useless or nonsensi¬
cal. Why use a strategy if it does not lead to change or growth? Resultant client
self-knowledge is a motivator for change through the enhancement of self-
awareness, self-understanding, and self-acceptance (Cormier and Cormier,
1991; Teyber, 1997). Interpretations are an excellent means of helping clients
achieve insight into their reactions and relationships and serve a multitude of
purposes. Weiss (1993) and other writers point out that through well-delivered
and well-timed interpretations,

• clients tend to become more self-aware, recognizing automatic reactions

or habitual ways of relating as they occur;
• clients learn to see themselves more accurately and positively, recogniz¬
ing how their needs, conflicts, coping styles, and defenses manifest in a
variety of settings and circumstances;
clients begin to understand their here-and-now affects, cognitions, beha¬
viors, and relationships in a broader context that ties them to past experi¬
ences and events;
clients come to accept their current responses and experiences because
they can begin to understand how they developed;
clients feel i educed anxiety about themselves and their reactions because
interpretations (or more accurately, explanations contained within them)
provide answers to pressing questions;
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 279

• clients feel reduced shame because they begin to understand how certain
responses developed and that they served adaptive purposes;
• clients can begin to let go of pathological beliefs because they can recog¬
nize their roots and original self-protective meaning, as well as the reality
that these beliefs are no longer warranted or needed;
• clients feel reduced helplessness because by showing how reactions de¬
veloped, interpretations imply that these same reactions can be changed
and are under the clients control.

The third assumption underlying the use of interpretations is one that is

occasionally violated by therapists or counselors. It is rather tempting to de¬
velop a way of interpreting human behavior and then to fit every single client
into that mold. It is extremely important to make sure that every given client is
seen as unique and that the specific circumstances of the clients life and de¬
velopment are considered when developing explanations and understanding.
Interpretations work only if they have been individualized for the client and ex¬
press the essence of the entire client. Interpretations are not formulas that can
be used equally for all clients (Nichols, 1987); they should not be phrased to fit
people in general; they cannot press people into a single mold; and they must
not be based on stereotypes, prejudices, or easy assumptions about what
“causes” certain behaviors (Ivey, Ivey, and Simek-Morgan, 1997). Instead, in¬
terpretations must fit the unique and highly personal, idiosyncratic history and
experience of each client. This issue was addressed above and will not be reit¬
erated further here except to once again emphasize its importance. There are
several other cautions that must be considered before a clinician delves into the
use of interpretations. It is very tempting for clinicians to share their insights
about clients’ behaviors as soon as they have occurred to the counselor or ther¬
apist. However, clinicians are usually far ahead of their clients in terms of un¬
derstanding what motivates clients’ reactions and relationships. If the explana¬
tion is rendered as soon as it occurs to the clinician, clients are often offended,
overwhelmed, startled, or shocked by the clinician’s revelation. Not surpris¬
ingly, such poorly timed interpretations tend to be the very ones clients will re¬
ject. Good timing and empathic delivery are the crucial components that
define a good interpretation. They will be achieved only if the clinician follows
a number of safety guidelines that help increase the likelihood of an interpre¬
tation’s success. These guidelines will now be explored as factors to consider
when using interpretations.

Factors to Consider When Using Interpretations

Because interpretations involve explaining currently manifested affects,
thoughts, behaviors, and relationships through past experiences or learning,
they can feel overwhelming, cold, imposed, or otherwise negative to the client
if they are rendered without preparation or outside of the context of a stable
280 CHAPTER NINE

and trusting therapeutic relationship. If an interpretation is verbalized prema¬

turely or without preparation, the discrepancy between where clients are with
regard to understanding their problem and how clinicians explain the problem
may be too large for clients to tolerate or accept (Cormier and Cormier, 1998).
An interpretation thus delivered will be perceived by the client as experience-
distant and will not have as much impact as an interpretation that is experi¬
ence-near and understandable by the client (cf., Kohut, 1984). Experience-
distance refers to a clients perception of an intervention by the clinician as
incongruent with the client’s current way of thinking, feeling, or understand¬
ing. The client perceives the counselors statement or action as sudden, unem-
pathic, or confrontational because it does not correspond to the clients current
experience or understanding. When experience-distance occurs in the thera¬
peutic relationship, clients tend to withdraw, react with anger, or experience an
intensification of symptoms. They perceive the relationship with the counselor
as similar to other conflictual relationships outside of the relationship and ex¬
perience a decrease in rapport and motivation for therapeutic work. Experi¬
ence-distance can get in the way of clients accepting a perfectly good interpre¬
tation and reduces the chance for creating change and growth.
Experience-nearness, on the other hand, implies that the intervention
chosen by the therapist resonates with the client in some way. The client feels
profoundly understood, cared for, or connected with the counselor. When an
intervention is experience-near for the client, the insight conveyed by the clini¬
cian makes sense to the client because it will feel right, corresponding to the
clients current experience or perception of the issue at hand. Experience-
nearness implies that the intervention was well-timed and more or less accurate.
It is i espectful of the client and the client s current needs and puts the client’s
speed or pace in therapeutic work ahead of the clinician’s needs for sharing
brilliant insights. Achieving experience-nearness and good timing is one of the
more difficult skills for novice clinicians. Often, when clinicians have achieved
an understanding of the client’s concerns, they want to share this insight and the
corresponding excitement. However, if this insight is perceived by the client as
not related or relevant to what is being discussed, the ensuing sense of discon¬
nection with the therapist is experience-distant. It is crucial to make sure that
the client is ready to hear an insight achieved by the counselor before it is de¬
livered. A context for the explanation must have been created; the client must
have been prepared (often carefully and slowly) for the explanation so that it is
not perceived as coming out of left field. If experience-nearness is achieved in
interpretation, the client is more likely to accept the interpretation (if it is ac¬
curate) and through this acceptance will change and grow.
It is helpful with regard to timing of interpretations to appreciate the dif¬
ference between understanding and explanation. A client always needs to feel
that a clinician understands a reaction (or need, or conflict, and so on) before
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 281

explaining it. Understanding, or rather the expression of understanding, con¬

sists of clinicians communicating that

• they have empathically heard the client

• they can accurately understand what the client is trying to convey
• they understand that it is logical and important for clients to react the
way they did given their current personality structure
• they do not judge the client

The expression of understanding is the verbalization of empathic concern

and acceptance. It implies that the clinician understands that the client feels no
choice about current affects, thoughts, behaviors, reactions, needs, conflicts,
coping choices, and relational patterns since all of these reactions are reflec¬
tions of who the client is at this moment in time. Understanding does not try to
explain why the client is that way. It merely expresses understanding of the fact
that the clients current personality (or self) leads to the clients current reac¬
tions, seemingly outside of the clients control. Once clients have repeatedly
felt understood and not judged by a counselor, they are more open to hearing
a feeling not only acknowledged, but also explained. An explanation focuses on
helping clients realize how they developed the personality style or self that
leads to the outward behaviors, affect, thoughts, and so forth. Understanding
accepts and acknowledges that clients’ personalities or selves lead to particular
reactions; explanation seeks to look at why the personality style or self devel¬
oped to begin with. Interpretations deliver explanations.
For example, a therapist working with a client who feels interpersonally
fearful and shy may right away have the insight that this behavior developed at
least partly due to the client’s learning history. Whenever the client expressed
interpersonal exuberance or engaged in behavior that was outgoing, her
mother chastised her and criticized her for wanting to be the center of atten¬
tion. Over time the client learned that she should not be outgoing and became
shy and withdrawn to avoid upsetting her mother and being criticized by her.
Although the clinician knows this explanation, it is best not to share it right
away. The client would perceive the explanation as experience-distant, and it
may even recapitulate the relationship with her mother. The clinician instead
empathizes with the client’s shyness and communicates to the client an under¬
standing of how difficult it is for the client to be outgoing and exuberant in so¬
cial settings. He expresses understanding whenever the client becomes self-
critical about her inability to be outgoing and sociable, verbalizing (reflecting)
the client’s need to stay on the fringe for now and to withdraw. The counselor
consistently supports the client in her choices and does not try to change the
clients behavior in anyway (yet). Once the client feels supported and accepted
in her relationship with the clinician, he can move toward an exploration of how
long the behavior has been in place, the circumstances in which it occurs, and
282 CHAPTER NINE

so forth. Once both counselor and client have gained a level of comfort in deal¬
ing with the issue on such a cognitive, exploratory level, an explanation (inter¬
pretation) becomes possible. Sometimes this process of setting the stage for an
explanation via a period of understanding takes a few minutes; sometimes it
may take months. The experience of the client in relationship to the clinician
will determine when the clinician moves from understanding to explaining.
When it is possible to move toward interpretation in the context of the clients
current experience in the therapy room, that is, wheri the explanation can be
received by the client in a way that feels experience-near, the counselor can de¬
liver it. Given the importance of good timing and careful delivery of interpre¬
tations, a few guidelines are best followed that are designed to increase the
likelihood that the explanation is perceived as experience-near by the client,
and the chance for growth and change is enhanced.

Guidelines for Using Interpretations

• It is best not to begin the interpretive process in therapy until a firm
therapeutic alliance has been established wherein the client has experi¬
enced ample understanding by the therapist.
• It is best not to use interpretations until after some of the more basic
cognitive strategies (outlined above and in the previous chapter) have
been used successfully on several occasions.
• Interpretations need to be phrased respectfully and gently; they should
never imply that the clinician is right and the client is wrong or that the
clinician has some special knowledge with which the client has to agree.
• Interpretations must not be used to blame, attack, humiliate, or deride
the client; careless phrasing of interpretations can make them sound
more confrontational or derisive than intended, thus, careful phrasing is
important.
• Interpretations need to be phrased to minimize defensiveness and guard¬
edness on the part of the client; they need to be worded so that the client
can perceive them as helpful and positive, not dogmatic or absolutely true.
• Interpretations must be idiosyncratically tailored to the client, never
making assumptions that what may explain a behavior or reaction for one
person will also explain it for another.
• Interpretations need to be relevant to and respectful of the entire person-
hood of the client and should never make clients feel only partially re¬
sponded to by addressing (explaining) only selected parts of them while
ignoring others.
• Partial interpretations are to be avoided as clients may wonder whether
the therapist only accepts and understands a part of who they are rather
than understanding them wholly and completely.
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 283

• Interpretations must be free of jargon; they must be phrased in common

language that is cognitively easy for the client to understand.
• Interpretations need to be phrased so that they are relatively concrete
and straightforward or must otherwise match the cognitive flexibility and
level of abstraction of the client.
• If a client does not have the requisite cognitive flexibility and level of ob¬
jectivity and abstraction, interpretations may not be the best strategy for
that client (for example, with children or developmentally challenged in¬
dividuals, interpretations should be used sparingly if at all).

If clinicians follow these guidelines, subsequent use of interpretations is

likely to be helpful and growth-promoting. Novice clinicians may need to wait
to use interpretations until they have learned to read clients well enough to
know when a statement will be perceived as experience-near versus experi¬
ence-distant. Interpretations are best not delivered as a monologue but rather
given piece by piece, perhaps even leading the client to verbalizing the insight
through guiding questions. The clinician can lead the client to the insight
through clarifying questions, without ever having to state it for the client. The
client makes the interpretation; the counselor merely paves the road for it. A
client who can arrive at an explanation through a process of clarifying questions
never perceives an interpretation as experience-distant because the client de¬
livers the explanation out of the current experience with the clinician. If a cli¬
nician is ever uncertain as to whether clients are ready for a given explanation,
it may be best to use clarifying questions first, to see if they can arrive there
themselves. To repeat an important point, when in doubt, clinicians should not
use interpretations. Much excellent therapeutic work can be accomplished
without this (perhaps somewhat overrated) counseling strategy. When the time
is right for an explanation, clients will accept it, in fact, they may verbalize it
first. Counselors need to learn patience and constraint in using this very ad¬
vanced and difficult strategy.
In terms of the actual mechanics of how to deliver or phrase an interpre¬
tation, there is no single way in which an interpretation is accomplished. There
are as many ways of phrasing an explanation as there are clinicians, clients, and
problems. It is impossible to provide a formula. Only practice wall lead to mas¬
tery of this technique.

Sample Transcript of Interpretation

Following is an example of an interpretation. This interpretive process could
have occurred in many different ways and still have met the criteria or guidelines
outlined above. The transcript demonstrates how the counselor first acknowl¬
edges and accepts the client (that is, conveys understanding). Then he moves
toward exploring why the client developed the type of personality structure or
 I

284 CHAPTER NINE

self that would result in the specific behaviors and needs. This exploration
through clarifying questions leads the client toward an understanding and ex¬
planation of his self or personality structure in a meaningful and experience-
near manner. The example demonstrates how questions and simple statements
can be combined to lead a client toward making an interpretation independently.

client: I just don’t know if I’ll ever be able to trust any woman enough
to ask her to live with me. It’s my experience that as soon as people move
in together, they forget they ever loved each other. . . .
clinician: You just don’t trust that love can survive the daily ups and
down of life. . . .
CLIENT: Exactly. You know, how much can you love someone when your
stomach is cramping or the phone is ringing off the hook or you have to
clean toilets. There’s just nothing romantic about cleaning and working
and taking care of physical needs. . . . You know, how can you love some¬
one if he farts in bed? (grins)
clinician: Love can only survive your best behavior. . . . (also smiles)
client: Something like that. So, there, now you know. I’ve really not en¬
joyed being alone but it’s the only safe thing.
clinician: And to you it’s important to be safe! (understanding)
client: Yes. I’m not much of a risk taker.
clinician: I understand that. It’s your way of being in the world. If you
don’t take risks, you don’t get hurt, (understanding)
CLIENT: Yes. You know, lots of people can’t accept that, though. I get
made fun of a lot for not being more daring. Being a guy, I guess it’s even
worse. I could see a woman getting by with my personality. . . . But some¬
how guys are expected to be bold and daring. You know, go all the way on
everything.
clinician: It’s hard to get people to accept and understand that that’s
just who you are and that you’re okay with that. . . . (understanding)
CLIENT: Exactly. You understand, though. . . . You’ve never pushed me
to take risks. ... I always thought counselors made you face your fears.
I was actually worried about that before I started seeing you, you know....
CLINICIAN: Would it make sense for me to push you into stuff that feels
risky?
CLIENT: No way—I wouldn’t come back. . . .
clinician: Yeah, exactly. And what good would that be?
CLIENT: But I’m still alone. . . .
clinician: Right. So maybe rather than us pushing you to ask someone
to move in with you, (grins) we could look at what experiences in your
life you’ve had that may have made it important to be safe, not to get
hurt, not to take risks. We may find there is a reason for why you are the
way you are. . . . (setting the stage for seeking explanations)
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 285

CLIENT: That makes sense. . . . But how do we do that? (puzzled)

CLINICIAN: Well, we could start by looking at some events in your life
when you felt unsafe, maybe even hurt, or scared. . . . We’ve talked about
some of those already. . . . What do you think?
CLIENT: Oh, there are plenty to choose from, I guess. You know, given
my father’s temper ...
clinician: Yeah, I kind of figured . . .
CLIENT: So were do I start?

CLINICIAN: Maybe at the beginning? Like with the first time that you can
remember when you were in a situation that felt unsafe ... or hurtful. . .
CLIENT: The first time. Hmm . . .
clinician: (nods encouragingly; allows for a long pause)
CLIENT: Well, it may not have been the first time but I remember one
time after we had moved into our new house when I was a little kid . . .
before my sister was born. My parents were fighting. . . . (hesitates; tears
up a little; then controls his emotions)
CLINICIAN: Uh huh? (semi-verbal encourager for client to go on)
CLIENT: Well, I remember I woke up in the middle of die night because
of a loud crash. It was pitch-dark outside—It must have been pretty late.
I didn’t know what was going on, so I got out of bed to check it out.
(hesitates)
CLINICIAN: What did you find out?
CLIENT: Well, the crash was my mother’s head smashing through the
window. She and my father were fighting again, something they were
doing a lot. She didn’t fall out the window. She came back at my father,
looking all bloody. He started screaming at her to get away from him. But
she kept coming. Then I saw her grabbing the fireplace poker and she
started chasing him through the living room. He was screaming at the top
of his lungs. But she was just quiet. She didn’t say a word, she just kept
chasing him. Finally, she swung at him. And cracked his shoulder. I think
he didn’t really think that she would do it. Otherwise, maybe he would
have left the room or something.
CLINICIAN: And where were you while all of this was happening?
CLIENT: I was standing there watching.
CLINICIAN: Standing where?
CLIENT: In the living-room door.
CLINICIAN: Did they realize you were there?
CLIENT: I’m not sure. I didn’t make a sound. They never said anything to
me. I finally went back to bed and hid under the covers.
CLINICIAN: How long do you think you stood there?
CLIENT: Well, at the time it seemed like an eternity, I’m sure. But it
must have only been a few seconds. They kept screaming at each other
after I went back to bed. At some point I heard my father leaving the
286 CHAPTER NINE

house. The next day he came home and he had his arm in a sling. I think
she broke his shoulder. He had his arm in a sling for a long long time.
CLINICIAN: Go back to that living-room door, would you?
CLIENT: Okay . . .
clinician: How old were you?
CLIENT: I was about five.
clinician: What do you suppose went through your mind as you were
standing there, watching your parents chase each other?
CLIENT: Probably not much. They did this a lot. I saw them fighting
many, many times, and I suppose I just kind of got used to it.
CLINICIAN: You got used to it?
CLIENT: Uh huh ...
clinician: You’re saying it didn’t affect you?
CLIENT: No, I don’t think so.
clinician: And yet somehow this is the event you thought of when you
were looking for something in your early life that made you feel unsafe or
that hurt you. . . . (mild confrontation)
CLIENT: Yeah . . . Well, I mean I must have been scared, I suppose. You
know, to see your parents going at it like that. . .
CLINICIAN: (nods)
client: My sister, you know, she is just like me. Scared, alone, doesn’t
trust anyone. But she wasn’t even born when this happened.
clinician: But you said it happened all the time. Did it happen after
she was born too?
client: Yeah. I guess so. Yeah. I should be honest with you. ... It hap¬
pened even more after she was born. My dad didn’t want another baby.
So he got meaner after she was born. Started hitting me, too. For any¬
thing. If I made noise, if I was quiet; if I played, if I just sat around. He
picked on her, too. . . .
CLINICIAN: On your sister?
CLIENT: Yeah. And my mother . . . My mother stopped hitting him,
though. Or maybe I should say she stopped defending herself. She would
sit there for hours, staring at the wall. My sister, when she still was a
baby, would scream and scream, and my mother did nothing. It would
scare me to death. I was worried she would die and my mother wouldn’t
notice. It was like they had forgotten about us. You know, life was so . . .
It felt like you couldn’t count on anything. Not even your next meal. And
all because life got too complicated for my father. . . . You know, like
when he had to face the daily chores of having a wife and lads, he fell out
ol love with all of us. . . . (looks profoundly surprised) Oh . . .
CLINICIAN: Oh!
CLIENT: There it is, isn’t it?
clinician: Tell me . . . (wants the client to give the interpretation)
 WORKING WITH THOUGHT AND COGNITION: ADVANCED 287

Skill Development Recommendations

Recommendation 9-4 Recall the movie or novel you chose in Chapter Seven
for the empathy exercise. For the lead, characters, identify how you would
express understanding (of what they are doing, feeling, thinking, and so on)
and how you would explain (why they are doing, feeling, thinking, and so on,
as they are). In the novel or movie, how and when did understanding emerge?
When did explanations become clear? Was the sequence leading to the under¬
standing and explanation optimal from a therapeutic perspective? Why
and how?

CLIENT: I learned this attitude from my father. . . .

CLINICIAN: Or at least you interpreted his behavior to reflect that atti¬
tude . . . And you felt firsthand how unsafe things were when you felt like
the love was gone. . . .
CLIENT: Yes! I learned to play it safe after that. I was a mousy kid. Took
no risks because the less I was noticed, the less I got hit. The fewer risks
I took, the safer I felt!
CLINICIAN: (nods encouraging client to go on)
CLIENT: So now I keep doing it. I try not to get into the situation my fa¬
ther was in by not letting daily life into my relationships. And I play it
safe in everything to keep from ever feeling that unsafe and scared again.
No wonder I’m still living alone. I guess its a miracle that I have dated at
all! (Session continues from there.)

This example demonstrates how a client can be guided toward profound

insights without much obvious explaining or interpreting by the clinician. The
counselor merely had to have the insight first, and then led the client with ques¬
tions to a place where he could realize the connections on his own. An inter¬
pretation made in that manner is an outgrowth of the client’s current experi¬
ence and hence is experience-near and of great impact. Had the clinician moved
directly into the interpretation after identifying the clients personality style,
the client might have rejected the interpretation. This is particularly likely as
he initially claimed that the fighting between his parents did not affect him. He
could not recognize the impact of the parental relationship until he was ready
for it, until he himself arrived at a memory and experience that created a feel¬
ing within him in the here-and-now. It is within the context of a here-and-now
experience that recapitulates a past experience that experience-nearness is
most easily and commonly achieved, setting a perfect stage for interpretation.
288 CHAPTER NINE

The example also demonstrated the working together of many therapeutic

strategies in a single exchange with a client. In a textbook, strategies may be
dealt with separately, but real life (or real counseling or therapy) does not work
like that. A clinician does not set out to use a single strategy; counselors use all
strategies they have at their disposal as they are needed, often many simulta¬
neously. In fact, skilled clinicians will not set out to use any strategy. They will
have all strategies ready in their bag of tricks and will pull out whichever strat¬
egy or intervention appears most appropriate when the context for it arises. It
is impossible to plan which strategy mental-health-care providers will use with
a given client. They will need to have the flexibility to use any strategy, de¬
pending on the needs of the client, any time.
Skills for
Affective Awareness
in Psychotherapy
and Counseling
■
;
 CHAPTER

Working with Affect

and Emotion

Overview and
Basic Skills

If we really want to live a full life, both the ancient

tradition of Buddhism and the modern one of
psychotherapy tell us that we must recover the capacity
to feel. Avoiding emotions will only wall us off from our
true selves—in fact, there can be no wholeness
without an integration of feelings.
Mark Epstein

That this book first dealt with issues of cognition is not to imply that work with
affect is secondary to or occurs after work with thoughts. Most commonly,
mental-health-care providers work with clients on many issues simultaneously.
They may be using affective strategies to help clients gain affective awareness,
while at the same time also dealing with clients’ thoughts and cognitions. Both
thoughts and affects need to be addressed, through the use not only of specific
cognitive and affective strategies, but also the many communication and ques¬
tioning skills that were presented as the basis of all therapeutic work in earlier
chapters.
Perhaps no aspect of humanity is more complex than that of feelings, that
is, emotional awareness, experience, and expression. Emotional awareness re¬
fers to a persons ability to recognize that feelings are present and a willingness
to accept that emotions are an important and genuine aspect of human experi¬
ence. Awareness, that is, the willingness to acknowledge that emotions exist and
play a role in the human experience, immediately precedes and is the founda¬
tion for the recognition of emotional experience. Emotional experience refers
to the ability to recognize subtle physical changes and to interpret them cor¬
rectly. Emotional awareness requires the individual to be able to take stock of
simple physical changes that occur when a certain affect is present and to learn
to label these emotions according to some agreed-upon semantic system. Aware¬
ness and experience help clients differentiate subtle differences between and
within emotions. They are intimately tied at every step of the process of gaining

291
292 CHAPTER TEN

affective self-understanding. A certain level of affective self-understanding has

to be gained before affective expression can be explored and altered. Affective
expression refers to the outer expression of the internal experience, which is
based on awareness that there is an internal experience. The three aspects of
emotionality, awareness, experience, and expression are closely tied; neverthe¬
less, it is important to recognize their separateness as well, as this has implica¬
tions for how to proceed with treatment.
Often clinicians fail to differentiate the three aspects of emotionality (aware¬
ness, experience, expression), for example, working with a client on emotional
expression without realizing that the client does not yet have clarity about in¬
ner emotional experience or even awareness. There must be a progression of
work with regard to affect. First, clients have to be aware that affect exists and
accept that it has legitimacy; then they can begin to explore how they experi¬
ence it to achieve full and conscious affective awareness in the moment. Only
after they have both awareness and internal experience can they turn toward
healthy and conscious outer expression. It is true of course that clients may re¬
act emotionally (that is, engage in emotional expression) without awareness of
this reality. They may deny vehemently that they are expressing an affective
state. Such emotional expression is neither conscious nor healthy as it is based
on a lack of awareness and is not consciously (internally) experienced by the cli¬
ent before or while being expressed. If a clinician were to attempt to alter such
a client s emotional expression, for example from anger to compassion, failure
would be very likely. The client would have no understanding of what it is the
clinician is getting at because the basic premise that affect is involved would
not be shared. Unconscious or automatic emotional expression is dealt with by
helping clients gain awareness of and accept their emotional self, followed by
an exploration of how affect is experienced internally. Only then can treatment
progress to working with altering emotional expression. The models of working
with affect that follow are based on this very premise. The first model will con¬
cern itself with the creation of awareness and exploration of inner experience,
as these two aspects of emotionality are intimately tied to each other and can¬
not be explained or understood in separation. Once this model has been clari¬
fied, a model for affective expression will be added. Since working with affect
requires a certain comfort level of the clinician, the chapter concludes with
helpful hints about how to facilitate and deal with emotional expression when
it occurs in session, either in a planned or spontaneous manner. It is imperative
that mental-health-care providers who invite clients to begin to experience and
express affect know how to manage emerging affects in session. The clinicians
ease and comfort with tolerating affect influences how safe (and successful) the
client is in allowing affect to emerge. Throughout the work with affect, clini¬
cians keep the strategies for managing affect in the forefront of their minds.
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 293

A Model for Affective Awareness

and Inner Experience

Although it may oversimplify matters somewhat, it is useful to think of affec¬

tive awareness and inner experience as consisting of a continuum That ranges
from absence of any emotional awareness whatsoever (including absence of
any conscious inner experience) to presence of awareness accompanied by
clear inner experience coupled with deep understanding. Many steps connect
this continuum, as will be outlined below and shown in Figure 10-1. Given this
conceptualization of affective awareness and experience, a model for working
with affect emerges that proceeds from helping clients gain awareness to rec¬
ognizing, accepting, and understanding their inner experience with clarity. The
clinician first has to establish the clients current level of affective conscious¬
ness and then proceed to help deepen affective awareness and understanding,
beginning intervention at the appropriate level. What follows is a discussion of
the conceptual model of assessment and of level of intervention. Actual strate¬
gies that can be used at each level of affective awareness and inner experience
are outlined in detail in the next chapter.
It should be noted that while the model is presented and proceeds in a lin¬
ear fashion, clients might not always present in this linear form. Especially at
the higher affective levels, some overlap may occur in the different levels of ex¬
perience. For example, acceptance of affect, dealt with below as Level Eight,
may begin to play a role in a clients affective experience as early as Level Six,
which deals with conflicted and mixed emotions. However, for ease of discus¬
sion these two experience levels are presented separately. As the reader moves
through the levels, it is important to remember that overlap across stages is
possible, in fact, likely, and that work always needs to proceed in a fashion that
is tailored to the individual client. Also, the reader will note that various exer¬
cises that work with affect will be recommended at more than one level of af¬
fective experience. When the same exercise can be used at different levels, this
implies that the exercise mechanics are the same, or similar, across purposes.
In other words, the mental-health-care provider may choose the same process
to go through with a client, but will do so for different reasons and with dif¬
ferent expectations about outcome. The purpose of the exercise will dictate
the level of depth that is pursued and the types, number, and nuances of affects
to be worked with and explored. The next chapter, which will detail the me¬
chanics of the exercises, will present examples at different affective experience
levels (where applicable) in the attempt to clarify how the same process (or ex¬
ercise) can be used for different purposes, to meet the clients therapeutic
needs arising at different levels. The model for affective awareness and inner
294 CHAPTER TEN

experience that follows is loosely based on research that has explored and
defined normal affective development (for example, Lane and Schwartz, 1986;
Stern, 1987).

Level One: Basic Awareness of Affect

The first step in this model of working with affect is the assessment of whether
a client is aware of affect. Many clients come to counseling or therapy with
painful affects and emotions but are not actually aware that this is so. Some ex¬
press affects outwardly without any inner recognition of this fact. For example,
a client may come across as hostile and angry and when queried about affect
may deny any awareness of angry emotions. Such a client enters treatment at
the most basic level of affective awareness and inner experience, unaware of af¬
fect within the self. This is not to say that this client does not talk about feel¬
ings. However, any discussion of feelings is just that: a cognitive treatise with¬
out true inner experience. Often talk about affect will involve the emotions of
other people or will recapture what others have claimed about the feelings of
the client, without the client having conscious experience of this affect person¬
ally. For example, many obsessive-compulsive clients have learned to talk about
feelings, without making any inner connection to the words they are using.
They will indicate that someone else (often an intimate partner or parent) has
referred them for treatment because that person perceives the client as de¬
pressed. The client will be able to detail what the referral source describes as
signs of depression. However, when asked how that depression feels to the cli¬
ent, the client will be unable to answer: Awareness and inner experience of the
affect is lacking. Clients who present at this point on the affective continuum
need to be worked with at a very basic affective level. Strategies focus on open¬
ing the client up to a very basic awareness of inner physiological experiences
that may later be correlated to feelings. Examples of such strategies are the
Breathing Exercise, Bodily Awareness Exercise, and the Basic Bodily Experi¬
ence Exercise (see the next chapter). Trying to force the client at this level to
explore feelings on a more advanced level will lead to frustration for the client
and the clinician. Instead, intervention will need to focus on slowly developing
physiological awareness in the client. The client will first have to learn how to
listen to the body in general; sometimes this may start as simply as exploring
with the client what it physiologically feels like to be hungry. Clients at this
level of affective awareness are so detached from their body that such basic ex¬
plorations can be difficult and challenging in and of themselves. Only when
some physiological awareness of physical feelings (hunger, thirst, sexual
arousal, aches and pains) has been gained will a progression to physiological ex¬
ploration of affects be in order and possible.
Is the client aware of the presence or aneci'
I i Intervention begins at this level:
Yes No —> Basic strategies that facilitate basic
i awareness

Can the client identify an inner (physiological) experience of the affect?

i l Intervention begins at this.level:
Yes No —> Advanced strategies to facilitate
basic awareness

Does the client know how to attach a basic label to the inner experience of the affect?
i i Intervention begins at this level:
Yes No —> Strategies to identify basic range of
^ affects; experience in here-and-now

Has the client avoided the development of this affect as a default affect?
i i Intervention begins at this level:
Yes No —> Strategies to identify basic range and
^ expand repertoire of affects

Does the client recognize levels of intensity (shades of gray) within a given affect?
si I Intervention begins at this level:
Yes No —> Strategies to identify levels of intensity
si
within any given category of affect

Does the client recognize mixed or conflicted affects?

si si Intervention begins at this level:
Yes No —> Strategies to explore affect overlap and
si
coexisfence (even incongruent ones)

Does the client know how to differentiate screen and underlying or base affect?
i i Intervention begins at this level:
Yes No —> Strategies to expose screen affects
and explore underlying affects
i
Does the client fully accept experienced affect(s)?
i i Intervention begins at this level:
Yes No —> Strategies to enhance acceptance
of affects

Does the client understand the origin and role of experienced affect(s)?
>1 si Intervention begins at this level:
Yes No —> Strategies to explore sources of affect
and to show that knowledge of “why”
can be used to alter “how” and “when”

Client has achieved full affective awareness and inner experience

-> Move to exploration of Affective
Expression (see Figure 10-2)

FIGURE 10-1
A Flowchart for Assessment of Level of Affective Awareness and Inner Experience
296 CHAPTER TEN

Level Two: Basic Inner Experience of Affect

If a client has basic awareness of physiological arousal and affect, the next level
of affective experience can be explored. The critical question at this level is
whether the client can identify the inner experience that goes along with some
kind, any kind, of emotionality. Some clients come to treatment complaining
that something “feels off,” that they “don’t feel right,” or that they are somehow
“out of kilter” (that is, there is affective awareness), but they are unable to ex¬
plain further. They have neither a label for nor an understanding of what that
feeling may represent. It is important to explore whether such a client can
identify the inner experience, or physiological state of being, that is associated
with this diffuse feeling of something not being quite right emotionally.
A client at this second level of affective awareness and experience will be
unable to identify or connect with a physiological response spontaneously. This
client may not even recognize that an “off feeling” has a physiological aspect to
it (diat is, is experienced in the body). Thus, intervention has to begin by link¬
ing the diffuse feeling(s) the client reports (but cannot identify!) to an internal
state of being. This can be done through interventions that help the client rec¬
ognize that mental states have bodily correlates that can be identified. Such
clients can be helped to recognize, for example, that when they say they feel
out of kilter, their stomach hurts or their neck is stiff. Linking such basic phys¬
iological reactions to the “off feeling” will help clients gain inner experience of
affects of which they are aware only in a very rudimentary form. Strategies that
are helpful with clients at this level include the Body Attunement Exercise and
the Basic- and Advanced-Bodily-Experience Exercises (see the next chapter).
Some clients at this level may have vague emotional awareness of some feelings
but are completely cut off from awareness of other affects. Although these
clients will label no affects yet with certainty, they may express more under¬
standing and may have more physiological awareness and experience for some
emotions than for others. For example, some clients may be able to connect
with feelings in the body that to the clinician may signal anxiety, but they may
not be able to identify an inner experience when their presentation appears
more depressed to the clinician. Clients may be at Level One with regard to
some feelings (in this example, depression) and at Level Two with regard to
others (in the example, anxiety).

Level Three: Labeling of Basic Affect

Clients may be aware of feelings that manifest physically within their body but
they have not necessarily labeled the feelings yet. In this instance the clinician
will need to ask the critical question that identifies the next, or third, level of
affective awareness and experience, namely, whether the client has a label for
that feeling and physiological state. It is not uncommon for clients to have a dif-
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 297

fuse feeling, to be able to explain where and how they feel it in their body, but
not to know what to call the emotion. Such clients may complain that they
“haven’t been feeling right” and may connect this emotional state to a physio¬
logical one, recognizing that when they feel poorly their head hurts, or they feel
fatigued, or they may have a tendency toward stomachaches. Even if such
clients do not verbalize the physiological correlate at first, they are readily able
to do so with some questioning. They may be able to recognize that they “have
butterflies in their stomach” or that their “heart aches.” If clients have this level
of awareness and recognition of inner experience, the next step involves find¬
ing out whether they can accurately and reliably label this emotion. Can the cli¬
ent differentiate whether this feeling is depression, anxiety, or anger? Often
clients are not able to do this. If clients lack labels for their emotions and their
inner experience, intervention needs to focus on helping them develop a basic
vocabulary for a basic range of feelings. No great sophistication is sought here.
The chent merely receives help in figuring out how to differentiate very broad
human emotions such as anger, anxiety or fear, sadness, happiness or joy, and
similar large categories of human affective experience. The labeling process is
easiest if the client has learned to relate different physiological reactions to cer¬
tain types of (yet unlabeled) experiential feeling states. The client who can
identify that feeling “off kilter” involves butterflies in the stomach and trem¬
bling hands, whereas feeling “out of it” involves a headache, increased sleep,
and lack of pleasure, will progress faster toward labeling than the clients who
have not yet succeeded in identifying different physiological states.
Once Level-Two work has helped clients identify a number of experience
states, labeling (Level-Three work) can begin. This is achieved by building on
clients’ inner (physiological) experience in the here-and-now. The Here-and-
Now Affect Exploration Exercise in a later chapter outlines the basic process for
such work, mainly by example. If a clinician recognizes, for example, that a cli¬
ent has arrived in a sad mood, this can be used as an opportunity to help the cli¬
ent learn the label for this current state of being by identifying, with the client,
the inner experience (essentially Level-Two work) and then attaching a label to
it. This is much the same process that occurs developmentally with young chil¬
dren, when a parent provides a label for an affect that is clearly experienced by
a child. Who has not heard a parent say something to the effect of “Yes, that was
really, really sad, wasn’t it? Those tears show just how sad you feel, don’t they?”
The same thing, perhaps in more sophisticated language, but perhaps not, will
occur in counseling and therapy with clients who are struggling to advance to
this level of affective experience. They need to learn basic labels for their inner
experience so that they can become more effective and efficient at recognizing
and communicating their feelings both in and out of treatment. Labeling of
feelings is only useful if the client clearly has identified the corresponding physi¬
ological or inner emotional state. Providing labels to a client without tying the
labels to experience will help the client talk about feelings without any better
298 CHAPTER TEN

awareness of what the feelings are really about. Caution is necessary not to jump
to labeling without experience work first (experience first, label later). It is bet¬
ter for a client to recognize a physiological process that signifies a feeling and
not to know the label for the emotion than to pick a convenient label without
truly knowing the physiological or inner manifestation of the word.

Level Four: Identification of Default Affect

As the client develops a basic repertoire of feeling labels, it is paramount to as¬
certain that the client does not just conveniently use the same label for all af¬
fects or respond to all experiences with the same affect. Sometimes, once
clients have learned to identify a particular affect, they generalize this label to
all emotional experiences. Such a generalization of labels can be called a de¬
fault affect; no matter what the client experiences, the label is always the same.
It is helpful for the clinician to sort out whether an affective label has become
a default or whether it is used genuinely. A clear indication that a label has be¬
come a default is when it is used exclusively. The counselor will note that the
client is applying the same label in all situations, to all bodily experiences. If
this happens, it is necessary to help the client recognize the singularity of the
affective-label choice. Once this recognition takes hold, the same interventions
are used as at the prior affective awareness and experience level. Work is done
to help the client expand the repertoire of experienced affects and their com¬
mensurate labels. This can be done by assisting clients in recognizing that a
range of affects are possible in any given situation and to differentiate labels
connected with different inner experiences. In some ways this level of assess¬
ment is a mere double-checking that the client has learned how to label a range
of affects, not just a single one, and may be viewed as an extension of the sec¬
ond and third levels. Interventions chosen at this level are therefore basically
identical to those used at Level Three.

Level Five: Identification of Affect Intensity

Once it has been established that clients correctly label their inner affective ex¬
perience in terms of broad strokes of basic feelings, the next level of affective
awareness and experience can be explored. At this level, differentiation with
regard to the intensity of a particular affect is assessed. Often clients who have
not quite reached this level, but who know how to identify and label basic af¬
fect, are unaware that there are shades of gray within each category of basic af¬
fects. They may not recognize that there are many intensities of anger, depres¬
sion, fear, joy, and so forth, focusing only on die broad category. If clients are
unaware ol nuances ol feelings within a broad category, intervention needs to
begin at this level. It focuses on helping clients identify the different levels of
intensity within each category of emotion, helping them develop labels for the
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 299

different shades of gray. Exact labeling may vary from client to client. The im¬
portant point is not to come up with an exact continuum or classification of
words, but a continuum of affective nuances within a category of affect for a
particular client. For example, for one client, anger may be broken down into
four sublevels of intensity, ranging from irritation to frustration to anger to rage.
Another client may feel more subtle differences and may end up identifying six
sublevels of intensity, perhaps ranging from irritation to exasperation to aggra¬
vation to annoyance to anger to fury. The point of intervention at this level is
to help clients recognize that feelings have subtle nuances and vary in intensity
across situations. Being able to differentiate subtle shades of feeling often helps
clients feel more in control of their affect as they do not have to feel that the
entire spectrum of affect is unleashed all at once all the time. For example, of¬
ten clients who are first learning to identify sadness become fearful of being
overwhelmed by depression and morbidity. They are afraid that just by label¬
ing a feeling as sadness, they will be utterly depressed. For such a client, sad¬
ness has only one intensity: overwhelming depression. It is helpful for such an
all-or-none client to recognize that sadness comes in many levels of intensity
and as such can be handled successfully. A client may recognize that having the
blues is a mild form of sadness that can easily be overcome with a simple strat¬
egy such as exercise. Differentiating the blues from despondency and despair
is helpful for this client. The exploration of intensity of affect can of course be
accomplished in many ways. A later chapter outlines the Affect Continuum Ex¬
ercise as a concrete example of the basic process that needs to take place with
a client at this level of affective awareness and inner experience. The Basic and
Advanced Bodily Awareness Exercises and the Here-and-Now Affect Explo¬
ration Exercise can be modified to render them helpful in letting clients expe¬
rience the subtle differences in physiological response at the different levels of
intensity of the same basic affect.

Level Six: Identification of Mixed and Conflicted Affect

Once clients can differentiate levels of intensity within a given category of af¬
fect, they are ready to be assessed for the next level of affective awareness and
experience, which deals with the recognition of mixed and conflicting feelings.
From a developmental perspective, the ability to hold conflicting or even just
differing affects at the same moment develops rather late. Children move
through affective development in a manner that progresses very similarly to
the levels outlined here. Most clients enter treatment at about this level of af¬
fective awareness and inner experience. They are not yet aware or cannot yet
accept that they can react with two completely different emotions to the same
event; for example, they may not be able to integrate feeling sad and angry
about the same thing at the same time. The experience of affect is viewed by
clients who have not yet achieved the identification of mixed and conflicted
300 CHAPTER TEN

feelings as something that is unitary, or confined to one type of emotion. Cli¬

ents at this level will be confused and unable to identify what they are feeling
when more than one affect emerges in a given context. Intervention is targeted
to helping clients recognize that affective experience is rarely unitary, but of¬
ten quite complex. Not only does a single affect have various levels of intensity
(as established at the prior level), but it is often accompanied by other affects,
which are also experienced at various levels of intensity.
Lack of recognition of mixed feelings often has to do with having a second
(or additional) emotion that may be perceived as inappropriate or unpre¬
dictable. For example, clients may experience both relief and anger at being
fired from a job that was very stressful. It is very likely that this client would
feel rather confused by the jumble of emotions that emerges after the event.
Such a client may come to counseling indicating confusion about the reaction
to the event, perhaps not being able to recognize or admit the sense of relief
that was experienced. While anger may be a predictable and acceptable emo¬
tion in response to being fired, the client may not perceive relief as a feeling
that should emerge. Confusion may arise from either an inability to recognize
that emotions can blend, or from an unwillingness to accept some versus other
emotions in certain circumstances. The focus of this level is less on those clients
who are unable to sort out what they are feeling because of not accepting a cer¬
tain affect (acceptance of affects being the focus of Level Eight). Rather, this
level is more concerned with assessing whether clients are able at all to expe¬
rience more than one emotion at the same time. Intervention at this level fo¬
cuses on helping clients recognize when more than one affect emerges at the
same time, when affects overlap and maybe even conflict with one another, and
when affects mix to blend into a new and unique affective experience that may
be quite difficult to label with a single word. The complexity of human emo¬
tions is quite clear to the client achieving this level of self-awareness. Explor¬
ing affect in the here-and-now will be one of the best ways to help clients be¬
come aware of their own emotional reaction and complexity as it will serve to
help them explore and experience when a blend of emotions occurs as it oc¬
curs. The Here-and-Noiv Affect Exploration Exercise used for various purposes
since Level Three will be helpful again here, as will the Basic- and Advanced-
Bodilij-Experience Exercises (all detailed in a later chapter).

Level Seven: Identification of Underlying Affect

Once clients can experience both nuances of single and mixed emotions, they
are ready to explore whether they have achieved the next level of affective
awareness and experience. At this level, the basic question has to do with the cli¬
ent s ability to differentiate screen affects from underlying affects. Clients who
have reached the affective sophistication to gain awareness of mixed and con-
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 301

flicted feelings are ready to explore when an affect they appear to experience
is the truly important and primary affect, and when it serves to cover a deeper
or more profound (often more painful) affect. Not all immediately identified
affects are at the base of the client’s experience. Often clients can become aware
of some affects and not of others. Affects that tend to emerge more readily and
that tend to fill in for or cover up more painful or underlying affects can be
called screen affects. Screen affects are the affects clients tend to be able to iden¬
tify easily and tolerate readily. They are affects clients have experienced often
and are familiar with. Clients generally have the resources to deal with these
affects and accept them freely and easily. However, the readily and easily ex¬
perienced affect may not reflect the clients true reaction to a situation. Instead
it may serve to cover up a more painful or subtle emotional experience of which
the client is unaware. This underlying affect may also be called the base or pri¬
mary affect. At this level (Level Seven), the client is assessed for the ability to
differentiate base and screen affects. This is accomplished via strategies that
help the client look deeper into their emotional experience and is often moti¬
vated by an intuition on the part of the clinician that the affect (screen) that is
being explored is not all there is to the client’s true experience. Clinicians often
recognize an affect as a screen before the client does and then through careful
questioning and here-and-now work with affective experience help the client
recognize a deeper and subtler affective response. Underlying affects are often
recognized first not as primary affects, but as mixed emotions. The client be¬
gins to get an inkling that there is another emotion that is perceived in a given
situation and, since having achieved Level Six, may perceive it as equal to the
other affect that was already identified. What differentiates an underlying af¬
fect from mixed emotions is that the screen affect often disappears once the
underlying affect is recognized. This is not true for mixed emotions. Here, each
emotion already identified previously continues to be felt even as additional
emotions emerge in the clients awareness. Primary or underlying affects are
often more painful and subtle, and the client often has reasons for not being
aware of them. They may represent affects that appear overwhelming, too
painful, or too profound. The type of work that is done with the client is very
similar, however, to that done at Level Six and the same exercises can be used
and modified for the specific purpose of exploring primary affects. The modifi¬
cations have to do with the clinician being more persistent in getting the client
to explore physiological states of being and being more forceful about here-
and-now explorations of emotional reactions.
Often in looking for underlying affects it is helpful to search for affects that
appear to be the very opposite of the affect already identified by the client. As
such, if the client identifies depression, it may be useful to search for anger; if
the client experiences anxiety, there may actually be excitement; exuberance
may cover sadness; fear may be a screen for aggression. Underlying affects are
302 CHAPTER TEN

often affects that have been projected and declared as alien by the client for
some reason or another. The client has disavowed the underlying affect, but has
attributed it to others in the environment. For example, a client may have strong
aggressive impulses. These, however, were not deemed appropriate in the cli¬
ents home and the client learned quickly to disavow this affect in the self. How¬
ever, because the aggressive affect remained, the client learned to attribute it to
an external source. Thus, the client came to view others as aggressive and con¬
sequently developed fear (of the aggressive impulses projected onto others).
Fear becomes the screen affect; aggression is the underlying affect. By pushing
past the fear, the client will recognize the underlying aggression and the fear
will resolve. Work then focuses on helping the client accept the underlying af¬
fect (that is, aggression), leading to Level-Eight work. As clinician and client
begin to work on underlying affects, both need to be prepared for painful work.
Clearly, this reality is yet another excellent example of why affective work pro¬
ceeds according to a careful model based on levels, in which intervention is tai¬
lored to the clients affective awareness and inner experience. That way, the
clinician does not push the client into therapeutic work for which the client is
not yet emotionally prepared. It is also at this level that the clinicians prepared¬
ness becomes paramount. The in-session management of difficult emotions be¬
comes important as clients explore new and painful emotional landscapes.

Level Eight: Acceptance of Affect

Identification of affects (especially of differing intensities, mixed emotions, and
underlying affects), no matter how profound and insightful, does not guaran¬
tee that a client will also accept the affect that is experienced. Level Eight is
concerned with exploring with the client whether affects that emerge (whether
they be mixed, conflicted, screen, or primary) are truly accepted by the client
as an important and valued aspect of the clients self-experience. For many cli¬
ents, acceptance is not a black-or-white issue. They are able and walling to ac¬
cept some affects, but reject others. Often clients can accept that they may feel
afraid or anxious, but reject the notion that they may respond in anger. Simi¬
larly, clients may accept their own sadness, but for whatever reason, cannot ac¬
cept their own pleasure or joy. Assessment of acceptance proceeds slowly and
cautiously, exploring the degree of a clients acceptance of each affect as it
emerges. Awareness of certain mixed emotions or underlying affects (work at
Levels Six and Seven) may be thwarted by lack of acceptance of those particu¬
lar affects. Thus, clients working at Level Six who are beginning to be able to
identify mixed and conflicted emotions may not be able to recognize or label
theii feelings in some instances, because they have not accepted one of the af¬
fects involved. In such cases, work at Level Six and Level Eight would have to
alternate. For example, the client might have to gain awareness of a certain af-
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 303

feet by itself, gain acceptance of it, and then learn to recognize it in a blend of
emotions.
In exploring acceptance the clinician needs to be sensitive to partial ac¬
ceptance or selective acceptance. There are many reasons why a client may not
accept a given affect. Possibilities include the following:

• the client is frightened of the affect

• the client is overwhelmed by the experience of the affect
• the client was not allowed expression of this affect during the develop¬
mental years
• the client is threatened by an affect

Understanding the reasons underlying lack of acceptance often has to pre¬

cede acceptance of any affects the client does not already value and accept.
Much of this work will have to be rather cognitive in nature and hence the
strategies covered in working with cognition and thought apply here. If lack of
acceptance derives largely from a sense of being overwhelmed by affect, relax¬
ation strategies can be helpful. For example, if a client has severe anxiety, that
person may be greatly assisted by learning how to calm the body and mind so
as to achieve greater equanimity even during normally stressful situations. Two
types of relaxation exercises, Progressive Muscle Relaxation and Focusing Re¬
laxation, are detailed in a later chapter. Breathing Exercises can be helpful as
well, both in and of themselves and as an integral part of the relaxation exer¬
cises. Additional helpful techniques that can be applied during interactions
with clients to facilitate affective acceptance include

• the mental-health-care provider s communicated acceptance of the

clients affect(s)
• the dispelling of myths about a particular affect
• the teaching of strategies for managing affects by which the client feels
overwhelmed
• normalization of the experience of affects the client perceives as
unacceptable or inappropriate
. reshaping of learning about certain affects during prior life experiences
. focus on here-and-now experience to desensitize the client to the affect
and to make it manageable and agreeable

Level Nine: Understanding of Affect

Acceptance of affects often is closely tied to understanding where and how a
particular affect developed or emerged. Thus, work at Level Eight and Level
Nine is often done simultaneously and without clear differentiation. Both lev¬
els heavily involve cognitive work, and although the levels are included here
because they are part of the affective awareness and inner-experience model,
304 CHAPTER TEN

the work involved in terms of intervention is actually cognitive in nature, al¬

ternating with affective work. One set of more strictly affectively-focused ex¬
ercises that can be used as well, however, is that of guided imageries. There are
endless variations of guided imageries; a skilled clinician can also use guided
imagery for earlier levels of inner awareness. However, it is recommended that
mental-health-care providers who want to apply guided imagery receive spe¬
cialized training with this powerful set of techniques.
Understanding of affect refers to helping the client become aware of how
and where certain affective response styles developed over the life span. It is a
process of helping clients recognize that there are at least two possible sources
for affects: the here-and-now occurrence, and past experiences that continue
to influence how the client responds in certain situations. The client is given as¬
sistance in differentiating when affects are truly an expression of a reaction to a
particular here-and-now event and when they are reactions that are ingrained,
learned in the past, and carried forward into the present. Often as clients rec¬
ognize why they have the affective experience they have, they begin to feel
more control over their emotional reactions.
If a certain affect, for example, was learned in the past and continues to
emerge in the present regardless of appropriateness, learning this may assist
the client in beginning to curb the affect in situations that do not really call for
it. For example, a client may have grown up in an environment that was highly
critical and learned that any performance presented to a parent was judged
harshly and deemed inadequate. The client slowly learned to associate feelings
of depression and self-loathing with having to present work. This client may now
be an excellent employee in a large firm who has responsibility for monthly
presentations of work done. Because of the strong association learned early in
life, the client may not be able to engage in these presentations without feel¬
ings of depression and despair. This maybe despite the fact that the clients em¬
ployer is very pleased with and praising of the work. The old experience and
ongoing expectation of criticism, however, overrides the current experience
and profoundly affects how the client experiences the situation. Clients who
learn of such connections (that is, gain understanding about their affects) often
feel profound relief and can then sjowly begin to learn to alter their affective
responses.

A Model for Affective Expression

Just as affective awareness and inner experience need to be thoroughly as¬

sessed to determine how to proceed with intervention, affective expression
also needs to be closely explored. Affective expression is explored in terms of
how it relates to the underlying inner affects experienced by the client, and
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 305

cannot be separated from affective inner experience and awareness. Thus, it is

best dealt with after the mental-health-care provider understands where the
client functions with regard to affective experience.
The main issues to be explored in the context of affective expression have
to do with how consciously and congruently the client expresses emotions to
the outside world. The suggested flow of questioning is shown in Figure 10-2.
One important note is necessary in the context of outward expression. There is
a great deal of individual variation with regard to how people express them¬
selves affectively. The same intensity of emotion may lead to two completely
different levels of intensity with regard to their outward expression. This dif¬
ference is largely mediated by personality style and emotional maturity. Intro¬
verts will be less expressive than extroverts; emotionally mature individuals are
less likely to overreact outwardly and may show a more tempered expression of
a like feeling. One example of this variation in expression may be that of many
practicing Buddhists who, despite heightened inner awareness, have very well-
modulated outer expressiveness. Their low expressiveness is not at all patho¬
logical or problematic, but rather healthily mediated by their spiritual beliefs.

Step One: Conscious Outward Expression

The first step is to ask whether the client evidences any outward expression of
affect, and if so, whether it is conscious. If there is no outward expression, the
first step will be to explore why this is so. If the client evidences no outward signs
of emotion because of a lack of awareness of affect, that is, because of no rec¬
ognition of inner experience, the clinician needs to backtrack to the exploration
of inner experience. Clearly, if a good assessment was done regarding awareness
and inner experience, this would not have to happen as the clinician would al¬
ready know that the client has no inner experience and would have begun inter¬
vention at that level. Occasionally, clients may have no outer expression despite
having some level of inner experience. There is a multitude of possible reasons
that can be explored for such a behavioral pattern. The client may be intellec-
tualizing or sublimating emotionality, expressing affect that is experienced in¬
wardly in outer ways that are out of the ordinary and not recognized as affective
expression. Such a client may work very hard when feeling anxiety, may exercise
when feeling annoyed, or may sleep longer hours when feeling sad. Alternatively,
the client may talk about the emotions rather than expressing them openly and
emotionally. This client may have intellectually stimulating conversations about
affects without ever letting on that this talk hides a profound inner experience
of that very emotion. The mental-health-care provider will know if this is the
case since questioning regarding inner experience would have provided enough
information about the client s inner awareness to let the clinician know that the
lack of outer expression is not congruent with the level of inner experience. If
306 CHAPTER TEN

Does the client engage in outward expression of affect?

i I Intervention begins at this level:

Yes No —■> Move to work with affective awareness
and inner experience

Is the client aware of this outward expression of affect?

i i Intervention begins at this level:

Yes No —> Catharsis and strategies that explore
I reasons for nonawareness of expression

Has the client avoided a ritualized (default) style of affective expression?

i i Intervention begins at this level:

Yes No —> Strategies that explore patterns and
i increase repertoire of expression;
facilitation of catharsis

Is the client’s affective expression congruent in intensity with inner affective

experience?

I i Intervention begins at this level:

Yes No —» Strategies that explore reasons for
i incongruence and create congruence

Is the client’s affective expression congruent in type or quality with inner affective
experience?

I ■i Intervention begins at this level:

Yes No —> Strategies that explore reasons for
i incongruence and create congruence;
facilitation of catharsis

Client has achieved healthy and conscious affective expression, congruent with inner
experience and awareness

-> Move to the exploration of other possible

reasons for seeking treatment at this
time (if assessed at intake) or consider
termination of treatment

FIGURE 10-2

A Flowchart of Questions for Assessment of All Aspects of Affective Expression

there is no outer expression although client and clinician have been working on
and have succeeded in establishing inner experience, then strategies will need
to be employed that facilitate outer expression. Most importantly, catharsis
needs to be encouraged. How to do this will be covered later.
Some clients will show outer expression of affect but upon query the men¬
tal-health-care provider recognizes that the client is not aware of this expres-
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 307

sion. The client is visibly exuding emotionality to others, but denies recognition
of this outer expression. If such unaware outer expression is accompanied by
lack of inner experience and awareness, the clinician will backtrack to work on
inner experience first. Occasionally, however, a client may have achieved some
level of inner experience without having recognized how this affect is evidenced
outwardly. It will be helpful to intervene by assisting the client m> recognizing
how certain behaviors and actions suggest affect to the observer. This process
will help die client build interpersonal as well as individual self-awareness. For
example, a client may appear clearly angry to the clinician. It may help the cli¬
ent to hear what affect this demeanor suggests to the clinician. The clinician may
gendy point out an intensely pitched voice, clenched fists, harsh vocabulary,
furrowed brow, and other physical signs of anger or hostility. Similarly, some
clients may be unaware of how their depression manifests outwardly. These
clients may benefit from being helped to recognize their slowed speech, low
voice, stooped shoulders, unkempt appearance, and similar physical signs. The
mental-health-care provider makes good use of knowledge about nonverbal
communication to work with this client who unconsciously expresses what is
felt inwardly. The clinician uses empathic statements to reflect back the client s
reality, applying knowledge gained with regard to strategies for facilitating
communication.

Step Two: Ritualized Outward Expression

The clinician also explores whether the affect that is being expressed is always
the same. Just as in inner experience, the mental-health-care provider has to
establish that the client does not default to the same affect in all situations. In
the case of outer experience, the clinician needs to assess how the client ex¬
presses affect outwardly. Is the expression the same regardless of the inner ex¬
perience? For example, does the client react with an angry, high-pitched voice
and clenched fists regardless of inner experience and outer situation? Do de¬
pression, joy, anxiety, and anger all look the same on the outside? If such ritu¬
alized expression of affect occurs, the client needs assistance in recognizing
how the outer expression comes across to those with whom interactions take
place. This is done in some manner of feedback, as discussed for Step One, us¬
ing good communication skills, knowledge about nonverbal information, and
cognitive-awareness skills. Occasionally, clients have ritualized outer expres¬
sion not because they express all inner experiences the same way, but because
they are stuck with an inner experience of a default emotion, that is, they are
stuck at Level Four of the inner-experience hierarchy. If this is the case, inter¬
vention has to be targeted there. Once the client is unstuck with regard to in¬
ner experience, outer expression should change automatically.
 308 CHAPTER TEN

Step Three: Congruence with Level of Intensity

It is also important to check whether an emotion that appears to be expressed
outwardly matches the intensity of the emotion as felt inwardly. It is not un¬
common for clients to show affect with either significantly more or less inten¬
sity outwardly than inwardly. This incongruence will result in miscommunica-
tion as observers will either over- or underestimate the client s given affect. For
example, some clients may express sadness with crying, slumped shoulders, a
sad face, and slowed movements, regardless of the level of intensity with which
they experience it inwardly. The client may verbalize that on a given day the in¬
tensity of sadness is at mild upset or at despair with regard to inner experience.
However, outer expression does not change. Another client may have the same
way of expressing an inner sense of anger regardless of intensity. Such a client
may be perceived as enraged even when the persons inner experience is one of
mild annoyance. The outer expression is intense regardless of inner experience.
Such incongruence with intensity needs to be explored first with regard to the
reasons for it. One possibility includes the absence of inner awareness about
subtle shades of gray in the experience of emotions. This lack of inner awareness
has left the client at a lower level of inner experience (Level Three or Four) and
has made correct identification of the subtle nuances of affect difficult if not
impossible for the client. If this is the reason for the client s incongruence, inter¬
vention needs to be targeted to the appropriate inner-experience level. Once
the clinician has clarified that the client has subtle and nuanced inner experi¬
ence, outer incongruence is addressed. For some clients, it may be necessary
to engage in cognitive strategies that actually teach modulation of affective ex¬
pression. An example may be a client who reacts with severe outer aggression
at the slightest hint of inner experience of anger. This client may have inade¬
quate controls over behavior and may benefit from anger management tech¬
niques, a psychoeducational approach to helping the client gain control over
this particular affects expression.

Step Four: Congruence with Type of Emotion

The final aspect of outer expression that is explored is that of congruence in ex¬
pression with mixed emotions or conflicted feelings. Some clients with con¬
flicted feelings express outwardly only one of the many feelings they may have.
For example, the client who has just been fired and experiences relief and anger
may only show hostility. The client does not express the full range of experi¬
ences that are perceived internally, leaving a whole aspect of self unexpressed
and creating the opportunity for miscommunication with others. Exploration
of this style of incongruence is identical to that in Step Three. First, the clini¬
cian has to assess whether the lack of differentiated outer expression is due to
lack of inner differentiation or recognition of conflicted and mixed emotions. If
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 309

this is the ease, intervention takes place at that level of inner experience. If in¬
ner experience is clear about the melange of affects involved but does not trans¬
late into outer expression, intervention takes place at the expressive level. It may
be important to determine whether the choice of which of the many experi¬
enced affects to express is driven by a ritualized outer expression of affect. Simi¬
larly, the clinician may want to double-check on the possibility of a screen af¬
fect receiving outer expression and the underlying affect not being expressed
even though it is experienced. Working back and forth between inner experi¬
ence and outer expression is critical in this step to make sure that intervention
is targeted to the correct cause of the incongruence. Once the clinician is clear
that the problem rests with outer expression, not inner experience, interven¬
tion can be focused on facilitating the expression of affects involved internally.
This is best accomplished by assisting the client with appropriate catharsis.

Facilitating Clients’ Affective Experience

and Expression in Session

The affective model, as discussed earlier, presented the clinicians need to be

able to draw out a client s inner experience and outer expression of affect. Draw¬
ing clients out emotionally is particularly helpful to intervention at the affective-
expression level but actually also supports the work done to create inner expe¬
rience. This is so because the facilitation of emotion—that is, catharsis—is not
only about outer expression of affect, but also inner awareness of how emotions
manifest in physiological reactions. Even though catharsis may be typically
thought of as facilitating an outer show of emotions, it is actually a process of
helping the client get in touch with feelings, both as they are experienced in¬
wardly and as they are expressed outwardly. Thus, the process of facilitating
catharsis is one that is applicable at all levels of affective work and is a valuable
standard tool for the mental-health-care provider. The same can be said about
empathic responding. It too is a therapeutic strategy that has ubiquitous ap¬
plicability in working with affect, as the careful reader has already noted.
The client s experience of catharsis is dependent upon the mental-health¬
care provider’s ability to help the client experience and ventilate feelings and
needs. The mere experience and subsequent release and expression of emotion
is highly therapeutic for many clients despite the fact that it necessarily leads
neither to internalization of change nor to insight and growth (Young and Be-
mark, 1996). Catharsis can be said to have a number of related benefits:

. catharsis is useful in helping clients gain recognition of the intensity and

type of affect that was formerly held in, repressed, or otherwise kept
from being experienced
 310 CHAPTER TEN

• catharsis is useful in helping clients express emotions according to the

intensity and type of affect that is felt and previously was not outwardly
demonstrated
• catharsis represents a recognition by the client that a strong inner affec¬
tive response exists and must be acknowledged through conscious inner
experience
• catharsis represents an acknowledgment by the client that a strong inner
affect is experienced that must find expression
• through the conscious inner experience of affect, the client raises inner
self-awareness and may increase affective acceptance
• through the outer expression of the affect, the client takes ownership of
and thus responsibility for the affect
• inner experience and outer expression of affect may facilitate a new self¬
perception and may lead to insight regarding the self in relationships

For catharsis, or ventilation (Corsini and Wedding, 1997), to take place, a

client has to feel safe in the therapeutic environment and accepted by the men¬
tal-health-care provider. Clients are well aware that catharsis does not neces¬
sarily result in the ventilation or release of only positive, but also of negative af¬
fects, affects that may appear quite frightening and overwhelming to the client.
Being in a safe place and with a person whom the client can trust is not sur¬
prisingly an important ingredient in actually allowing for inner experience and
outer expression to occur. Because catharsis can lead to sudden and perhaps
painful or overwhelming experience of affect, there are some clients with pre¬
senting problems or diagnostic presentations for whom catharsis may not be
the best course of action or experience early on in the therapeutic relationship.
For example, clients with post-traumatic stress disorders may best not be en¬
couraged to become affectively aroused early in treatment as their level of
arousal may become too intense to be easily tolerated and helpful (Young and
Bemark, 1996). Histrionic clients may already be overemotional; encourage¬
ment of catharsis with such clients may be counter-therapeutic in that it en¬
courages a means of expression that is already overused. Encouragement of
catharsis must be a conscious choice by the clinician that is carefully tailored to
the specific needs of each client.
There are a number of variables that can either hinder or help with the
process of catharsis (see Table 10-1 for an overview). As already mentioned, the
client needs to perceive the therapeutic environment as safe and supportive.
Additionally, the clinician needs to be able to communicate acceptance of the
client i egardless ol what affects may emerge. The client must feel perfectly se¬
em e in the assumption that the clinician will not be turned off by angry, hos¬
tile, demeaning, or otherwise negatively flavored affects that may reach the cli¬
ent s awareness or that may be expressed. Additionally, the mental-health-care
provider must be clear about giving permission for the experience and expres-
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 311

sion of all affects. The expression has to be safe, of course, and it is the clinician’s
responsibility to let clients know that they are capable of assuring such safety.
The ability to communicate permissiveness and safety about affective experi¬
ence and expression also rests on the clinician’s personal willingness to partici¬
pate in a cathartic process and to allow it without being personally frightened
or overwhelmed by it. Knowing how to manage affect is of particular impor¬
tance in this regard. If mental-health-care providers feel secure in their own
ability to help the client modulate expressed affect when this is necessary, or
retreat from overwhelming inner experience if this should be the requirement,
then they will be able to communicate this trust and security to the client. In
turn, the client will feel less frightened and more open to experimentation,
knowing that the clinician will set appropriate safety limits and will keep the
client safe. Allowing clients uninhibited expression of affect is not easy, espe¬
cially for novice counselors who may not be sure yet whether they will indeed
be able to contain a client’s affect once it is experienced and expressed. Not sur¬
prisingly, newer clinicians may inadvertently and unintentionally inhibit a cli¬
ent’s affective experience or emotional expression because of their own uncer¬
tainty about what to do once a strong affect emerges. The process of catharsis
can further be hindered by clients’ tendencies to want to avoid affective
arousal. Only a therapist who is able to help the client maintain arousal safely
and to express it productively will be able to make the cathartic process thera¬
peutic and helpful (Young and Bemark, 1996). For these reasons, facilitation of
catharsis can be considered a quite-advanced therapeutic skill that requires
careful self-awareness about possible stumbling blocks on the part of the clini¬
cian (Brems, 1999).

Dealing with Clients’ Affect in Session

As indicated above, if clinicians attempt to apply counseling skills that facilitate

affective experience and expression in clients, they also must know how to deal
with emotions when emotions do burst forth. In fact, even clinicians who are
not particularly keen on allowing for emotional catharsis do not really have a
choice about this matter. Most clients enter counseling because they are in an
emotional crisis; their propensity toward affective expression, whether con¬
scious and healthy or unconscious and unhealthy, is high. Mental-health-care
providers need to be prepared to deal with the emotions clients bring to ses¬
sions and need to have a certain comfort and confidence in realizing that they
can handle anything a client has to offer. Dealing with client affect is not all that
difficult as long as the clinician is prepared for it and has a template for how to
deal with feelings when they do emerge and appear to overwhelm the client.
Following are a few guidelines that can be useful. They clearly do not represent
 312 CHAPTER TEN

Factors to Consider in Facilitating Catharsis

Variables Variables
That Encourage That Squelch
Variables That Affective Experience Affective Experience
Encourage Catharsis or Expression or Expression

• Safe environment • Clinician’s lowered voice • Clinician's fear of clients’

• Private, confidential • Clinician’s slowed body affect in general
environment language • Clinician’s fear of certain
• Environment that does not • Clinician’s ability to affects
allow for interruptions tolerate affect • Clinician taking premature
• Environment conducive to • Clinician’s encourage¬ measures to regulate affect
emotional experience and ment of the client to stay • Clinician asking questions
expression (e.g., lighting, with affective experience about content while client is in
comfort) • Clinician’s encourage¬ an affective state
• Clinician’s conveyed ment of the client to stay • Clinician becoming focused
willingness to allow with affective expression on cognitive issues
affective experience • Clinician’s ability to draw • Clinician intellectualizing
• Clinician’s conveyed the client’s attention to • Clinician giving advice
willingness to allow hints of affective • Clinician providing premature
affective expression experience or false reassurance
• Clinician’s openness to • Clinician’s ability to point • Clinician becoming noticeably
affective arousal in self and to outward signs of upset
others affect • Clinician becoming fearful of
• Clinician’s knowledge about • Clinician’s ability to client’s emotion
how to deal with affective express empathic • Clinician overidentifying with
experience and arousal concern client
• Clinician's ability to set • Clinician’s ability to stay • Clinician providing sympathy
safety limits by helping with the client and com¬ instead of empathy
regulate affect and municate understanding
expression throughout the affective
• Clinician’s ability to let client experience
know that affect can be • Clinician’s expression of
contained if needed caring without shutting
• Clinician’s ability to the client down
communicate safety

the only ways in which feelings can be safely contained, but they give the novice
mental-health-care provider a starting point from which to expand. This dis¬
cussion is based on Brents (2000), where the reader can find additional detail.

Dealing with Loss of Control Over Emotion

Even the most out-of-control affect cannot last forever; in fact, it usually can¬
not even sustain itself for a whole session. Consequently, depending on the
amount of time left in a session, the first approach to apparent loss of emotional
control is to let it play out as long as it is not destructive to the client. The
catharsis that comes from allowing the emotion to flow freely for a while is of¬
ten quite helpful for the client as long as the affect is not accompanied by seri¬
ously uncomfortable physical feelings or dangerous behaviors. For example,
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 313

out-of-control anger may need to be reined in if the client appears to be on the

verge of violent action; a panic attack is always controlled to prevent the client
from hyperventilating or experiencing other severe physical consequences.
If the emotion is one for which catharsis is appropriate (for example, de¬
pression or sadness, frustration, or anxiety that is not of panic proportions), this
is the first choice. The intensity displayed by the client will decrease on its own
once the affect has been given free rein for a while. If the length of time
elapsed becomes too long (either because the session is almost over or because
either client or therapist becomes too uncomfortable), the clinician can calmly
begin to take steps to deal with the affect. This is started by asking the client to
begin to focus on the counselor. (For example; “I need you to: look at me; look
up; catch my eyes; look at my hand; . . .”) Next, any behavior connected to the
affect is talked about and stopped. (For example: “I want you to stop pacing
now; please sit back down” or “I need for you to stop bouncing your leg and
picking on your hair” or “Please stop wringing your hands.”) In so doing, clini¬
cians lower dieir voice significantly and speak much more slowly than usual,
but with emphasis. Once clients have stopped the associated behavior and have
begun to focus on the clinician, the clinician can ask clients to pattern their
breathing after the therapists. (For example: “Lets get your breathing back to
normal. Follow my lead. Slowly breathe in. . . . [clinician takes a long, calm
breath] and out. . . [clinician releases the breath forcefully]; in . . . and out.. . .)
This joint rhythm of breathing is maintained until the client becomes notably
calmer. All along, the counselor remains keenly aware of her or his own per¬
sonal body language, which is most effective if it expresses confidence, calm¬
ness, and collectedness. This is one time when the mental-health-care provider
definitely does not want to mirror the client’s body language. All demeanors on
the clinicians part exude relaxation and calm. For clients who lose control over
their affects on a regular basis, it may be useful to develop a structured and pre¬
dictable sequence of interventions for dealing with this situation. Not only will
this help clients begin to be aware of how to regain control over affect with the
therapists help in session, but they are also able to begin to use the same, reg¬
ularly rehearsed, strategies outside of the session.

Dealing with Uncontrollable Crying

If uncontrollable affect includes uncontrollable crying and this crying needs to
be stopped (again, if feasible, catharsis is the first choice as it may be sufficient
to stop die crying in and of itself), a few additional strategies are available.
First, handing clients a box of tissues is usually a nonverbal signal that it is time
for them to pull themselves together. Once clients have been given this non¬
verbal message to alter their behavior, clinicians ask them to look directly into
their eyes while talking calmly to the clients. (For example: “I am going to help
you stop crying now so that we have enough time to talk about what happened
314 CHAPTER TEN

before you have to leave today. I need you to look into my eyes—look directly
into my eyes.”) Once clients are able to maintain firm eye contact, the same
breathing exercise mentioned above can be initiated. The clinician encourages
clients to blow their nose to clear their head. The reason for the insistence on
firm eye contact is simple: It is physiologically difficult to cry and focus ones
vision at the same time. Thus, if the client is asked to focus on the clinicians
eyes, crying will automatically stop in most cases. Occasionally clients will re¬
spond to increased eye contact with more intense experience of affect. If a clini¬
cian encounters such a client, eye contact may not be the best method to stop
the client from crying. However, in most cases eye contact is incompatible with
crying. Clients can be taught this trick for home use as well—they can simply
look at and focus on their own eyes in a mirror and get crying under some con¬
trol. If the breathing exercise can be added in such independent practice, calm¬
ing will almost always be assured.

Dealing with Strong Anxiety Reactions and Panic

A strong anxiety reaction or panic attack requires intervention much sooner
than the type of emotion referred to above because it often is self-perpetuating
and can be physically dangerous. Highly anxious or panicked clients have phys¬
iological responses that further frighten them and often serve to increase the
panic. The actual intervention is not very different from that outlined above.
However, it is even more important that the clinician appear calm, in control,
and capable of setting firm limits. (For example: “I have to stop you from
NOW” or “You need to stop talking about . . . now" or “We need to move on
NOW to think about how to get you ready to leave today.”) The practitioner
uses voice and body language to underline the command nature of the direc¬
tives, providing verbal and physical structure (for example, handing the client
a tissue box; taking away the pillow the client may be beating, stopping the cli¬
ent from twirling hair, perhaps by physically moving and then holding on to the
hand). The clinicians voice must be firm but caring, as well as calm and con¬
trolled. Once the structure has been set, the client is asked to find a focal point
and to place total attention on it. Once the client has established eye contact
with the focal point (for example, a picture in the therapy room), the client is
asked to describe it. (for example: I need you to look at. .. right there across
from you. Okay, now tell me what you see. Describe it in detail.”) This simple
task serves to shift the client s locus of attention away from the distressing
thoughts that fuel the anxiety or panic. All the while, the clinician also needs to
pay attention to the clients breathing. If the client is hyperventilating, interven¬
tion in this arena is imminently important. This can be accomplished through
the same breathing exercise outlined above, in which the client is asked to model
breathing frequency and intensity after that of the therapist. In extreme cases,
the counselor may need to ask the client to breathe into a paper bag or through
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 315

a straw (or to engage in any similar strategy that prevents overbreathing). As

was explained with regard to intervening with other out-of-control affects, it is
important to slow all interactions with the client to a calm level. This is accom¬
plished through lower and slower voice. All along, the clinician gives reassur¬
ance about the safety ol the room and setting, doing so with calming firmness.
If the client is still panicking, it is often helpful to ask the person to pick up a
pillow and hug it tightly to the body. This action helps reestablish some body
boundaries and may help with any beginning symptoms of depersonalization.
Any and all of these strategies can be combined in any order depending on
what the clinician believes most likely to work. If the client is hyperventilating,
the first step of intervention would be the breathing exercise; if the client ap¬
pears to have a sense of loss of boundaries and self, the pillow intervention is
best (if no pillow is available in the room, clients can hug a purse or bag; or as
a last resort, can hug themselves firmly around the torso). If the client appears
extremely cognitively preoccupied, the focal-point exercise is best. Combining
strategies can be easily accomplished as well, in that the client can hug a pillow,
do slow breathing, and focus on a specified object (including the clinicians eyes)
all at the same time, while the clinician calmly talks about the safety of the room
and the setting. Certainly, whenever anxiety is high, the client may need spe¬
cial help with transitions of any sort, including beginning and ending sessions
or changing topics within sessions. Specific instructions, more time, clear di¬
rections, and similar structuring events may assist clients in moving more suc¬
cessfully through the treatment process even while highly anxious or agitated.

Dealing with Anger and Hostility

If the counselor or therapist is faced with an angry, agitated, or hostile client,
the primary concerns become the diffusion of the affect and maintenance of
behavioral safety for client and therapist. It is best not to challenge the accu¬
racy or truthfulness of an agitatedly angry client, and this is increasingly true as
the levels of anger and agitation rise. Rather than challenging, counselors are
best advised to acknowledge the clients feeling and validate it. (For example:
“I certainly understand that you are very angry right now. And I can certainly
see why. After all, what happened to you when . . . was very upsetting.”) It is
important to remain calm and not to get defensive, even if the client s affect
and behavior become a personal attack against the clinician (“And its all your
fault. If you were a better therapist you would have helped me by now”). In
other words, it is very important not to get caught up in the clients affect. If,
for example, clients accuse clinicians of various transgressions or misdeeds,
clinicians are advised not to defend themselves but rather to acknowledge the
clients experience. NOT: “I think you are wrong there. I really have been do¬
ing my best, but you have not been following the advice or recommendations I
have made.” And NOT: “If you had listened you would know that that is not
 316 CHAPTER TEN

what I said. What I really said was. . . .” Instead, say “I understand that you feel
as though I have let you down. Please tell me what I could have done differ¬
ently to help you better.” Or “I really appreciate that you are disappointed in
therapy. We have not progressed as much as you wanted. . . .” or “I am sorry
that you heard me as so critical of you. How could I have said things differently
that would not have been so hard for you to hear?”
While acknowledging clients’ affects and validating their right to them, ther¬
apists insist on basic safety rules. In other words, clients are allowed to get an¬
gry, but they do not have permission to act out this anger physically in aggres¬
sive or hostile ways. Behavioral boundaries on clients’ actions have to be very
clear. (For example, yelling is fine, so is hitting a pillow; but acting out physically
against the counselor or breaking therapy-room furniture is not). The mental-
health-care provider may choose to avoid too much direct eye contact if the cli¬
ent escalates, and should generally not touch the agitated client. Providing ex¬
tra interpersonal space can also be helpful. Especially when dealing with angry
affect that appears to have the potential to be acted out, clinicians are advised
to remember the caution never to be a hero. If a client becomes too agitated or
openly aggressive, it may be time to end the session or call for help. It is gen¬
erally clear to a therapist when a situation reaches a danger zone of potential
physical aggression. The clinician will begin to feel unsafe and will sense a loss
of control on the client’s part that involves not merely affective but behavioral
control. The strength of a client’s voice in and of itself is generally not the best
predictor. Better predictors are a client’s eyes and physical movements. Specific
physical symptoms that signal increasingly angry affect include muscle twitch¬
ing or restlessness, getting up and pacing, pantomiming aggression (such as
pounding, choking someone, beating), staring or lack of eye contact, shallow
breathing, quivering or loud voice, clenched fists, and angry words. When
counselors begin to notice these symptoms, quick diffusion of the affect is im¬
portant or the session may need to be discontinued. This resolve is communi¬
cated to the client directly as it may often serve to diffuse the behavioral reac¬
tion. (For example: “Unless you can calm down a little bit, we will not be able
to keep working today.”) Similarly, if the clinician feels the need to end the ses¬
sion or call in a helper, an explanation is given. (For example: “I believe we are
no longer safe in this room because I am sensing that you are about to blow up.
Let’s stop for today and continue our work next. . . or “Let’s stop for a mo¬
ment and call in one of my colleagues to get her or his perspective on this issue.”)
If the clinician is working with a client who regularly and predictably be¬
comes uncontrollably angry, it is a good idea to plan ahead and have supervi¬
sion and consultation available. If the mental-health-care provider is lucky
enough to have videotaping facilities or one-way mirrors, it is best to have a col¬
league watching the session from the other room. Thus, if the clinician mis¬
judges the intensity of the client s affect and behavior, help is immediately avail¬
able. If this route is chosen, the clinician needs to make sure that the observer
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 317

does not overreact. It is best for the clinician and the observer to agree on a
(nonverbal) sign that tells the observer when to intervene. If nothing else,
knowing that backup is available will help the therapist feel less nervous and
concerned, and thus more emotionally accessible and available to the client.
Even with the knowledge about how to handle in-session affective crises,
it must be noted that it never pays for a counselor to be heroic and that it is im¬
portant to know when it is time to seek assistance (Beliak and Siegel, 1983). If
clients are imminently dangerous due to out-of-control anger and hostility,
clinicians need to get help; if therapists are anxious and unsure about their abil¬
ity to manage a crisis, they need to seek input and immediate consultation or
supervision. If mental-health-care providers anticipate working with danger¬
ous clients on a regular basis (for example, due to a caseload of court-referred
clients), it is best to be prepared in terms of special equipment as well. Such
clinicians may consider having an alarm system in place, as well as a backup
support system of staff who are present in the clinic when (certain) clients are
being seen. If a client is extremely dangerous, but the counselor would like to
attempt to manage the crisis on an outpatient and immediate basis, confiden¬
tiality may have to be weighed against safety. In that instance the clinician may
want to consider having someone else monitor the session through video or
one-way mirrors.

Dealing with Depersonalization and Dissociation

During an episode of depersonalization, a client loses a clear sense of self and
feels detached from the self. Sometimes this manifests by perceptions of being
out of the body, being an automaton, or otherwise being a spectator of the self
as opposed to being in control of the self. Reactions of depersonalization are of¬
ten closely tied to anxiety and a loss of sense of personal boundaries. Not sur¬
prisingly, the same techniques that have been outlined so far (for emotional
control, for anxiety and panic, and for racing thoughts and pressured speech)
all are useful to some extent. The breathing exercise may be the most impor¬
tant and effective exercise as depersonalization can be due to overbreathing
(Beliak and Siegel, 1983) or underbreathing, where clients breathe so mini¬
mally that they fall into a trance state (Linda Olson-Webber, 14 August 1997,
personal communication). In severe cases of overbreathing, asking the client to
breathe into a paper bag or through a straw may be helpful. The pillow-hugging
exercise is very useful in that it provides the client with some definite body
boundaries that can be experienced very concretely. If the hugging is not
enough in and of itself, the clinician may ask the client to explain what it feels
like to hug the pillow, focusing on establishing a clear perception of body
boundaries. (For example: “Tell me how the pillow feels. Is it soft? hard? and
“On which parts of your body can you feel the pillow? your arms? where else?”
and “Tell me how your stomach feels with the pillow pressing on it” or “Squeeze
 (

318 CHAPTER TEN

the pillow a little tighter. What changes can you feel? Where can you feel the
additional pressure in your body? in your arm muscles? on your stomach?”) Us¬
ing the client’s name can be helpful in getting the clients attention. Beginning
all verbalizations by repeating the clients name is good routine practice.
For clients prone to dissociation—that is, clients traumatized as children
or adults by events such as chronic and inconsistent abuse, combat, natural dis¬
asters, and so forth (Pope and Brown, 1996)—the therapist must learn to pace
sessions carefully and must prepare signals (explained below) for the client to
become alertly oriented to the present and to return to the safety of an unaltered
state of consciousness. Dissociation-prone clients need help in learning to rec¬
ognize the feelings and thoughts they have that might signal the onset of a dis¬
sociative experience so that they may learn to prevent the episode from occur¬
ring both in and out of sessions (Sanderson, 1996). Careful pacing of clinical
material is critical to avoid retrieval of painful memories that is too quick and
painful and triggers a dissociative episode. As explained by Gil (1988), it is most
helpful to determine when dissociation occurs (in what setting or under what
circumstances), its precipitants (the specific events that lead to the flight re¬
sponse), and emotions associated with it. Further, the client is helped to under¬
stand dissociation as an adaptive strategy developed for purposes of psychic or
emotional survival. Once clients have gained this understanding, they can be
taught alternative strategies of coping or defense under circumstances that
usually would trigger a dissociative response (relaxation exercises, activities for
purposes of distraction, conversations with supportive others, and so forth). If
dissociation occurs during a session, the clinician needs to be prepared to as¬
sist the client in regaining a normal, alert state of consciousness. This eventu¬
ality is best prepared for by developing a bridge between the dissociative or
trauma-related state of consciousness and the present or nondissociative state
of consciousness (Dolan, 1991). One such bridge is called “symbol for the pres¬
ent,” wherein the client is asked to identify an item in the clients possession
that can be used as a reminder of the here-and-now. Should a dissociative event
threaten or occur, the symbol of the present can be used by client and clinician
to bring the client back to a normal alert state (Dolan, 1996). A similar bridge,
also recommended by Dolan (1996), is called “the first-session formula task” in
which the client is asked to make a list of events or activities that are currently
ongoing in the clients life to which the person has a strong positive commit¬
ment. The list is then used during dissociative periods to remind the client of
current resources that were not available at a time in life when the dissociative
defense was developed. A third bridging or grounding technique developed by
Dolan (1991, 1996) is called “the older, wiser self.” This technique involves
seeking advise from an older, wiser version of the clients self during stressful
periods that can be invoked to prevent a dissociative episode. This older, wiser
self is described to the client as follows:
 WORKING WITH AFFECT AND EMOTION: OVERVIEW 319

Skill Development Recommendations

Recommendation 10-1 Since clinicians cannot help clients grow beyond

the level of affective awareness that they themselves have attained, self-
evaluation about affect is important. Using the information in this chapter,
take an honest inventory of your own level of affective awareness, experience,
and expression. Talk to a trusted friend for additional insights. If this exercise
proves inconclusive or overly difficult, this will be a good time to seek per¬
sonal therapy or counseling.

Imagine that you have grown to be a healthy, wise, nurturing, old woman (or man) and
you are looking back in this time in your life in which you were integrating, processing,
and overcoming the effects of the past experience of sexual abuse [or other traumatic
event]. What do you think this wonderful, old, nurturing, wiser you would suggest to
you to help you get through this current phase of your life? What would she/he tell you
to remember? What would she/he suggest that would be most helpful in helping you
heal from the past? What would she/he say to comfort you? And does she/he have any
advice about how therapy could be most helpful and useful? (Dolan, 1996, p. 406)

All of these centering or grounding techniques can be used to return the

client to the here-and-now. More explicit techniques that involve imagery have
also been described (for example, Sanderson, 1996). These grounding tech¬
niques encourage clients to imagine themselves as a tree with a strong root sys¬
tem that is anchored in a safe setting and is indestructible even by the most
powerful forces. Such visualization exercises can help the client regain equi¬
librium after a dissociative episode, as well as being useful in preventing disso¬
ciation during stressful periods (Sanderson, 1996).
 CHAPTER

Working with Affect

and Emotion

Focus on the Body

I have repeatedly stressed how afraid people are to feel

their bodies. On some level they are aware that the
body is a repository of their repressed feelings, and
while they would very much like to know about these
repressed feelings, they are loathe [sic] to encounter
them in the flesh. Yet in their desperate search for an
identity, they must eventually confront the state of
their bodies.
Alexander Lowen, 1967
(quoted in K. Wilber, 1993, p. 241)

Once mental-health-care providers have a clear idea about the conceptual un¬
derpinnings of working with affect, that is, understand how to appreciate a cli¬
ents awareness, inner experience, and outer expression, they are ready to plan
and use affective strategies for intervention. As detailed in the previous chap¬
ter, levels of inner experience and outer expression have clear implications for
how to intervene around affective issues. A variety of affective strategies can be
used to assist clients in achieving awareness and gaining clarity about inner ex¬
perience. This then will translate into congruence with outer expression. Sev¬
eral of these exercises can be used at multiple levels of inner experience and
therefore for multiple purposes. Their basic mechanics remain the same regard¬
less of level, but their purpose and content of implementation will vary slightly.
Table 11-1 provides an overview of affective strategies along with level of in¬
tervention with regard to inner experience, and the specific purposes for which
the exercise is useful at a given level. The exercises covered in this chapter all
share a common focus on and use of the body (or of select parts of the body or
processes) as a means of helping clients achieve affective awareness or gain a
deeper understanding of their affects at higher levels of affective experience
and expression. The exercises in the next chapter will be focused more directly
on affect itself, with bodily explorations being secondary.
320
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 321

All throughout this and the next chapter, words that are spoken by the
mental-health-care provider directly to the client are placed in quotation marks
and blocked format. These words need to be spoken in a well-paced manner.
It is better to go too slow than too fast. Some practice may be required to get
the pacing just right. Ellipses, that is, three periods (...), indicate places
where the clinician is to pause for a moment before moving on. The length of
the pause is idiosyncratic to the client and will need to be adjusted as the clin¬
ician becomes familiar with a given clients needs. Actions the clinician takes
while practicing a particular exercise with the client are printed in italics. Ba¬
sic comments and instructions to the mental-health-care provider are printed
in regular typeface. Any directions that need to be tailored to insert a clients
particular affect or body area are placed in [brackets]. The content in the
brackets will consist either of an example or a directive as to what to fill in the
brackets. None of the instructions (including introductions and debriefings)
has to be used verbatim. All transcripts are simply examples and reflect the
content that needs to be covered; how this is accomplished will be up to each
individual mental-health-care provider. In fact, it is best not to work from a
transcript while with the client, even during exercises for which clients close
their eyes. The rustling of paper can be distracting, and the pacing is often not
as attuned as when the clinician speaks from memory. Although this may seem
overwhelming at first, none of the scripts is actually very difficult. Memorizing
the gist of each is usually pretty easy and just takes little bit of practice.

Focus on the Breath

Breathing exercises have their greatest applicability at Levels One and Eight of
affective inner awareness. However, they are an integral part of many of the af¬
fective exercises, being used in abbreviated form at the beginning of the Bodily-
Awareness Exercise, the Basic-Bodily-Experience Exercise, the Body Attune-
ment Exercise, and the Relaxation Exercises. They can be useful in helping
clients begin to explore inner sensations of their body, helping them gain aware¬
ness of physiological processes. They are often the first and best way to introduce
clients to working with their body to reach the goal of increasing affective aware¬
ness and experience. Some clients feel less threatened by listening to the phys¬
iological processes of their body than by talking about affect directly. For these
clients, breathing exercises are an excellent way to start. Breathing exercises fa¬
cilitate relaxation and calming; they can be a relaxation strategy in and of them¬
selves or can become an integral part of other, more formal relaxation exercises,
such as the ones to be covered in the next chapter. Some information about
breathing was already provided in the chapter on self-care. Review of this ma¬
terial should be helpful here as that knowledge may be shared with clients as
well. To reiterate a few of the important points about and benefits of breathing:
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324 CHAPTER ELEVEN

• breathing is helpful in that it draws attention to an important physiologi¬

cal process that can be felt in the body
• focus on breathing can assist with relaxation and calming
• paying attention to the breath can help clients slow down their responses
and can be helpful in delaying automatic behaviors and reactions
• many people hold their breath when stressed, a process that only further
increases the tension in the body
• deep breaths can be refreshing and rejuvenating
• learning to pay attention to the breath can help clients gain control over
affect

Basic Breathing Exercise at Level One of Inner Experience

The simple breathing exercises that are practiced widi clients at the basic¬
awareness level are focused on helping the client explore the breathing process
as an example of a bodily sensation. As the client at this level has not paid a lot
of attention to the body, much of the instruction for the exercise focuses on
helping clients listen to their body. Modeling is helpful in the sense that the
clinician will breathe in the same rhythm and pattern as is requested of the cli¬
ent. Such breathing is done audibly so that clients can follow what the clinician
is talking about. What follows is an example of an introduction, a transcript, and
a debriefing for a simple breathing-awareness exercise. The introduction only
has to be given the first time a breathing exercise is used with a client or if a cli¬
ent appears to have forgotten the basic premises of the exercise. The instruc¬
tions are used whenever a breathing exercise is used with the client. The de¬
briefing will be longest the first time a breathing exercise is used. Then it will
be applied in abbreviated form upon subsequent application.

Introduction to Basic Breathing Exercise

“One thing that people often find helpful in learning more about their
body and their feelings is to begin to pay attention to their breath. There
are many good reasons why we need to learn to pay attention to our
breath. For one thing, a lot of times when we are in difficult situations,
we actually hold our breath. That, of course, is not a good thing because
it tenses the body and reduces the amount of oxygen that is available to
the brain. So learning to take nice deep breaths can be very refreshing
and very calming. Learning to pay attention to the breath also has the
advantage that it teaches us a lot about our bodies. Learning to pay atten¬
tion to where we feel the breath, as it enters and leaves the body, often
helps us figure out how our bodies work and has the positive side effect
of getting us more in tune with the workings of our body. This is often a
first step in learning more about feelings and emotions that we might
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 325

have. So, what I would like for you to do at this point is to sit or lie back
and make yourself as comfortable as possible.”

The clinician also settles back and models a comfortable seated position. If the
client decides to lie down, that is acceptable. However, the clinician remains
seated.

You might want to go ahead and place one of your hands on your stom¬
ach. This will help you follow your breath on the outside of your body
with your hand as well as on the inside of your body with your mind.
However, if putting a hand on your belly is not comfortable, you can
also rest your hands on your sides or in your lap or wherever they feel
comfortable.”

For modeling purposes, the clinician places and leaves one hand on the abdo¬
men during the whole exercise.

“One diing we will focus on as we breathe is diaphragmatic breathing.

This way of breathing is automatic for babies, but as adults we tend to
have forgotten how to do it. The trick babies know is to use their dia¬
phragm as a means of pulling the air more fully into the lungs. Most
people breathe using only their chest muscles.”

Here, the clinician points to the intercostal muscles between the ribs.

“That’s actually a pretty inefficient way of breathing. If you breathe that

way, the abdomen doesn’t move when you inhale. Only the chest ex¬
pands. In diaphragmatic breathing, you will actually focus on observing
the rise and fall of your abdomen. When you breathe in, you will try to
make sure that your abdomen extends; when you breathe out, it pulls
back in.”

Here the clinician models a full diaphragmatic breath, allowing the abdomen to
swell on inhalation and to retract on exhalation, while also demonstrating the
correlated expansion and contraction of the chest.

“The reason that movement happens is that in diaphragmatic breathing,

we use the diaphragm to help gather in as much air as we can. The
diaphragm is the big muscle right here between the abdomen and the
chest.”

Here the clinician points to the general area of the diaphragm, that is, to the
large muscle between the thoracic and abdominal cavities.

“When you breathe in, the diaphragm flattens or expands downward.”

Here the clinician makes a hand motion to show the movement of the diaphragm
by sweeping down from below the chest cavity to the abdominal cavity.
326 CHAPTER ELEVEN

“That motion of the diaphragm pushes the abdomen out to make space
for the lungs to expand with air in your chest.”

Here the clinician points to the abdominal and thoracic cavities and models the
extensions of an inhalation.

“When you breathe out, the diaphragm shrinks back, making room for
the abdomen to flatten.”

Here the clinician models a full diaphragmatic breath, making sure to extend
and retract the abdomen and chest as appropriate; exaggeration of the move¬
ment may be helpful to make the point of using the diaphragm.

“Does that make sense to you?”

The clinician now answers any questions the client might have about diaphrag¬
matic breathing.

“I will be doing the breathing exercise with you. So you can also pay at¬
tention to my breathing sounds and maybe pattern your own breathing
rhythm after mine. Keep your eyes closed, though, and your attention
focused on your own breathing. If you find that my rhythm is too fast or
too slow for you, feel free to breathe at a rate that is most comfortable
to you.”

The clinician will watch the client’s breathing during the exercise and will at¬
tempt to find a rate and rhijthm that works for the client. Thus, it should be rare
that the client will have to find a rate or rhythm different from that modeled by
the clinician.

Instructions for Basic Breathing Exercise

“Now that you are seated comfortably, go ahead and close your eyes. This
will draw your attention to the inside of your body. Try to consciously fo¬
cus your mind inside your body and then follow my instructions. Start by
taking a deep breath in through your nose and then out through your
mouth. Follow my example.”

Here the clinician takes in a deep audible breath through the nose and then
blows the breath out through the mouth. This may be done a couple of times.

“And now breathe in”

Clinician inhales audibly.

“. . . and out through your nose.”

Clinician exhales audibly through the nose.

“And in . . . and out. . . and in . . . and out.”

 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 327

Clinician establishes a comfortable audible breathing rhythm. This should be

done without speaking for about twenty to thirty seconds, or whatever period
of time is comfortable for the client.

“Now as you breathe, begin to pay attention to where you can feel the
breath in your body. . . . For example, notice how the breath feels as it
enters your nose; . . . feel the coolness of the air in your nose . . . and no¬
tice the movement of the small hairs inside your nose. Keep breathing
in . . . and out... at a comfortable rate.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.

“Now notice how the breath feels ... as it approaches your lungs . . .
through your throat. Notice the cool air . . . entering your body through
your throat. . . and pay attention to how your stomach rises ... as the
air . . . enters your lungs. As you breathe in, . . . allow your belly to
expand comfortably; . . . allow your abdomen to extend ... to make room
for your lungs ... to take in as much air as possible. Keep breathing
in . . . and out... at a comfortable rhythm.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“And in . .. and out.

“Often when we breathe we don’t allow our stomach to inflate; . . .
instead we just expand our chest. We can’t take in nearly as much air
this way as when we allow our stomachs to expand. So, with your next in¬
halation, be sure to allow your belly to rise, . . . and then draw the breath
into your lungs. . . . Take a few nice deep breaths, in . . . and out, . . .
at a gentle rhythm, and notice the sensations of your body as it takes in
air; . . . draw your attention to your nose, . . . your throat, . . . your stom¬
ach, . . . and your lungs.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales a\{fiibly.

“And in . . . and out.

“Now notice the sensations as your breath leaves your body. . . .
Notice how your stomach flattens when your diaphragm begins to pull
328 CHAPTER ELEVEN

back. . . . Feel your lungs expelling old stale air through your throat. . . .
Notice how much warmer the air is that leaves your body ... as it moves
through your throat... up into your nose . . . and out through your nos¬
trils. Now keep breathing comfortably, . . . either following my rhythm . . .
or establishing your own, . . . paying close attention to all of the differ¬
ent sensations you experience ... as the breath enters . . . and leaves
your body.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

The clinician continues the exercise for a few minutes, observing the client’s vis¬
ible physical movements. After a comfortable amount of time, the clinician asks
the client to end the breathing exercise as follows:

“Now that you have observed the movements and feelings in your body
as you breathe in and out, I’d like you to bring back your awareness to
this room.... Slowly begin to focus your attention away from your body...
and to the outer world. . . . Do that by beginning to notice any sounds
that you may hear and when you’re ready go ahead and open your eyes.”

Debriefing of Basic Breathing Exercise

After each use, but most importantly after the first use of a basic breathing ex¬
ercise, the clinician debriefs the experience with the client. Attention is paid in
particular to any sensations of which the client was aware during the exercise.
It may be necessary to ask the client specific and detailed questions, since the
issue for clients at this level of affective awareness is that they are not consciously
aware of what goes on in the body. The clinician asks about sensations in each
involved body part, as well as overall questions. The more often the exercise
has been repeated, the less intense the querying during the debriefing needs
to be. Also, if clients spontaneously offer a lot of Sensory information, clinicians
have to do less probing. The hope for the debriefing is that it facilitates greater
awareness in clients not only as relevant to the current event, but also with re¬
gard to what they will attend to during the next time that the exercise is prac¬
ticed. All clients can be encouraged to practice the exercise on their own. This
encouragement is best given as a suggestion, not as a directive. The debriefing
also needs to explore whether the client had any negative impact from the ex¬
perience. This is unlikely, as the exercise is a fairly innocuous and pleasant one.
It is best to check nevertheless, to modify the exercise accordingly the next time
it is used.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 329

Advanced Breathing Exercise at Level Eight of Inner Experience

At this level of inner experience, the client is already highly self-aware. Thus,
breathing exercises at this level have a different purpose. They are used to give
clients a strategy to calm or center themselves, either through calming breath¬
ing by itself or in combination with relaxation exercises. The focus here is on
using breathing as a strategy that can stand alone. The use of breathing in com¬
bination with a relaxation exercise is similar; the main difference lies in its ab¬
breviation. The introduction to the breathing exercise is very similar to that at
Level One; it serves to introduce the client to diaphragmatic breathing. If the
clinician has been using Level One exercises with a client, a lengthy new in¬
troduction is not necessary. The client is merely told that the original breath¬
ing exercise will be used again, but this time with a different purpose. The pur¬
pose is then quickly explained and should make sense given the current issue at
hand in session. The clinician can then delve directly into the basic instruc¬
tions. What follows are the instructions for the advanced breathing exercise for
a client who has practice with the basic exercise. Only brief new directions are
given in the introduction as these are essentially the same, and both mental-
health-care provider and client are familiar with the basic mechanics. For a cli¬
ent with whom breathing exercises have never been used, the introduction will
be a mixture of the basic and advanced introduction and the client needs to
learn some basic diaphragmatic breathing before focusing on calming. De¬
briefing is identical in mechanics and differs only in purpose. As a reminder, all
directions in brackets indicate that the mental-health-care provider should fill
in the text appropriate to the client.

Introduction to Advanced Breathing Exercise

“Do you remember the breathing exercises we used to do? Well, they
have another application. They can also be very helpful when you try to
calm yourself down. When you use the breathing exercise for this reason,
you focus on slightly different things than you focused on before. Yes, you
still use your diaphragm, and you still pay attention to using your abdomen
and your lungs correctly. But primarily you use the breathing exercise
now to give yourself a sense of calmness and centeredness. You can use
the exercise anytime and anywhere. No one will be aware of what you are
doing. So whenever you feel. . . [insert the clients problem affect here],
just use a variation on the exercise we will practice in a minute to calm
yourself down and to slow down your reaction. Would you like to try this?”

The clinician now gives the client a chance to ask questions and may or may not
explain further how the client can apply the exercise alone during stressful
situations.
330 CHAPTER ELEVEN

Instructions for Advanced Breathing Exercise

“Seat yourself comfortably and close your eyes. Draw your attention to
the inside of your body. Try to consciously focus your mind inside your
body and then follow my instructions. As always, lets start by taking a
deep breath in through the nose . . . and then out through the mouth.”

Here the clinician takes in a deep audible breath through the nose and then
blows out the breath through the mouth. This may be done a couple of times.

“Breathe in ... ”

Clinician inhales audibly.

“. . . and out. . . through your nose.”

Clinician exhales audibly through the nose.

“And in . . . and out. . . and in . . . and out.”

Clinician establishes a comfortable audible breathing rhythm. This should be

done without speaking for about twenty to thirty seconds, or whatever period
of time is comfortable for the client.

“Now as you breathe, . . . begin to pay attention to where you can feel
your [problem affect] ... in your body. For example, notice how the feel¬
ing may affect your [head, ... or neck, ... or stomach]. All the while, . . .
keep breathing in . . . and out... at a comfortable rate.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

“Now allow your breath to bring in a calming, . . . centering energy
with each inhalation . . . and to expel all [negative affects] with each
exhalation.”

Clinician inhales and exhales audibly.

“And breathe in calmness . . . and breathe out [your anxiety].”

Clinician inhales and exhales audibly.

“And in with tranquility . . . and out with [negativity].”

“With each inhalation, . . . become more aware of the calm . . .
warm . . . energy that begins to permeate through your body. . . . Notice
how each in-breath helps relax . . . your [neck,. . . head] and how it
spreads a quiet peacefulness through your body. . . . Draw that calmness
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 331

in . . . through your nose, . . . down your throat, . . . and deep into your
lungs.”

Clinician inhales and exhales audibly.

'And breathe in calm . . . and breathe out [any anxiety].”

Clinician inhales and exhales audibly.

“And in with warmth . . . and out with [depression].”

“Now allow each out-breath to take with it the [negative feelings]
you tend to have. . . . Allow the [anxiety] to leave your body with each
exhalation.”

Clinician inhales and exhales audibly.

“And breathe in restfulness . . . and breathe out [upsetness].”

Clinician inhales and exhales audibly.

“And in with peacefulness . . . and out with [agitation].”

The clinician continues the exercise for a few minutes, observing the client’s vis¬
ible physical movements, repeating the instructions for inhalation and exhala¬
tion occasionally, but not on each breath.

“And breathe in calm . . . and breathe out [anxiety].”

Clinician inhales and exhales audibly.

“And in with warmth . . . and out with [sadness, depression],

“Now allow each out-breath to take with it the [negative feelings]
you tend to have. Allow the [anxiety] to leave your body with each
exhalation.”

Clinician inhales and exhales audibly.

“And breathe in restfulness . . . and breathe out [hurt, pain, discomfort].”

Clinician inhales and exhales audibly.

“And in with peacefulness . . . and out with [agitation].”

After a comfortable amount of time, and when the client has visibly calmed, the
clinician asks the client to end the breathing exercise as follows:

“Now that you have welcomed calmness . . . and peacefulness . . . and

expelled all [negative emotions], I’d like you to bring back your aware¬
ness to this room. . . . Slowly begin to focus your attention away from
your body . . . and back to the outer world. Do that by beginning to no¬
tice any sounds that you may hear. I will slowly count back from five to
one and with each number you will become more and more alert. When
332 CHAPTER ELEVEN

I get to one, you will be fully alert. Then take what time you need, and
when you’re ready open your eyes.”

Clinician slowly counts back from five to one and then allows the client to pace
her or his own return by opening the eyes.

Debriefing of Advanced Breathing Exercise

The mechanics of the debriefing are identical to those for the basic exercise.
However, the purpose is not to find out what sensations the client was able to
identify in the body, but rather on assessing how successful the client was in
calming and centering. Questions are focused on exploring where the client
could feel calmness and relaxation and where the client was successful in elim¬
inating negative emotions and sensations. Some processing about why some ar¬
eas of the body may have relaxed whereas others did not may be necessary. The
more often the exercise has been repeated, the less intense the querying dur¬
ing the debriefing will be. If a client spontaneously offers information, the clini¬
cian probes less. Clients can be encouraged to practice breathing on their own
during situations that are triggers for negative affect. As recommended above,
encouragement is given as a suggestion, not as a directive. The debriefing also
explores whether the client had any negative impact from the experience. Some¬
times a client may not be successful in expelling the negative affect and may get
into an inner struggle between tranquility and negativity. If this happens clients
may feel as though they failed the exercise. The clinician needs to be careful to
point out that a first attempt does not guarantee success and may need to help
clients find some small indication by which an improvement in emotional state
occurred. This small change can then be the definition of success and can be¬
come the springboard for better results next time. All clients should be given
more than one or two opportunities to try this exercise if it seemed to fail the
first time. Asking clarifying questions about what worked and did not work for
the client is particularly important in instances when success was low to mod¬
erate. Appropriate alterations can then be made during the next application
with the same client.

Focus on the Body

Several exercises fall into the category of focusing on or gaining awareness of

the body. Of course, strictly speaking even the breathing exercises fall into this
category as they focus the attention on the breath and the parts of the body af¬
fected by it. The exercises included in this section focus on the experience of
the whole body, or at least major parts. Each exercise can be shortened if needed
to hone in on certain parts of the body; however, all transcripts are written to
explore the whole body. These exercises are not yet concerned with identifying
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 333

Skill Development Recommendations

Recommendation 11-1 To become familiar with what may be asked of

clients in the future, begin to practice the breathing exercise as described for
Level One. Do this at a set time every day. Many people find it helpful to do
this type of breathing either first thing in the morning upon awakening, or as
the last thing of the day, before going to sleep. Choose a routine that fits best
into your day to make it more likely that you will stick with the practice.

affects; they are strictly geared toward guiding clients to begin to recognize that
the body has physiological sensations at all times. On the surface, these exercises
are quite similar. However, there are profound subtle differences that need to
be noted. For example, the Bodily-Awareness Exercise and Body Attunement
Exercise cover the same parts of the body, and the introductions to them are
very similar. However, there is one profound and planful difference: The aware¬
ness exercise assumes that the client is not yet capable of independent bodily
awareness and hence incorporates movements of body parts to catch and direct
the client’s attention. The movement inherent in this exercise is planful in that
it is not large, deep, or painful movement, but merely motion to give the client
a hook for awareness. In the attunement exercise, the client has gained some
ability to listen to the body. Movement may detract from feeling the body. Thus,
the client now is directed to draw attention to the same body part, noting only
what is already there. Once the client is attuned to the body, the clinician
moves to the next step, the Basic-Bodily-Experience Exercise, wherein more
emotional and feeling words are used (hence its categorization as a bridge ex¬
ercise). No attempt is made initially (that is, at lower levels of affective experi¬
ence) to label bodily experiences as signaling a specific affect; only the concept
is introduced that feelings and physiological responses coexist in the body.

Bodily-Awareness Exercise
This exercise is a natural extension of the breathing exercise in that it chal¬
lenges clients to get to know even more about the sensations in their bodies. It
guides the client through the exploration of various parts of the body to gain fa¬
miliarity with internal physiological reactions. The exercise directs the client to
pay attention to particular parts of the body and then to move these parts in
certain ways, paying attention to what each movement feels like. This process
helps the client identify and recognize internal bodily sensations. The exercise
334 CHAPTER ELEVEN

can be modified for individual clients. With some clients, the mental-health-
care provider may cover all parts of the body, spending as much as twenty min¬
utes in the exercise. With other clients, the clinician may begin with only a few
parts of the body, making the exercise shorter and more targeted. For some
clients shorter exercises may be appropriate if there are parts of the body the
clinician does not want to include the first few times this exercise is used. For
example, clients with a history of sexual abuse may be threatened by the focus
on particular parts of the body that are normally included in this exercise (for ex¬
ample, the buttocks or the chest). The genitalia are not included in this aware¬
ness exercise as they may be difficult to deal with for too many clients. What
follows is an example of a general introduction to this type of exercise, and a
transcript for an entire body awareness focus (that is., all parts of the body are
included). The transcript is written for a client who is seated. Minor adjust¬
ments will be necessary if the transcript is used with a client who is lying down.
The script is written to ask the client to attend to and move the body bilaterally
(that is, both feet, hands, arms, legs, and so on at the same time). With some cli¬
ents such a dual focus may not be possible and the mental-health-care provider
may alter the transcript first to work a given body part on the right side and then
on the left side (right foot to left foot, right calf to left calf, and so on). Clini¬
cians may also want to adjust this transcript to adapt it to the needs of a given
client, both in terms of time available to complete the exercise and in terms of
presenting symptoms. The amount of time spent on breathing can be short¬
ened or lengthened as needed. If a client is already familiar with and adept at
the breathing exercise, less verbal instruction may be necessary than with a cli¬
ent who still struggles with breath focus. The transcript is followed by com¬
ments about debriefing.

Introduction to Bodily-Awareness Exercise

“You know the breathing exercises we have been doing? Today I’d like to
introduce you to an exercise that is similar in the sense that it also gets
you to focus on what is going on in your body. But its different in that
this time the focus will be on many parts of your body and you will have
do certain movements to learn to be aware of what your body feels like in
certain situations. We’ll start the exercise with the same kind of breadline
that we have been doing and then I’ll ask that you just follow my instruc¬
tions. I will ask you to pay attention to different parts of the body at dif¬
ferent times and will ask you to move them in certain ways. Then I’ll ask
you to pay attention to what it is that you are sensing in that body part.
Does that sound acceptable to you?”

The clinician now gives the client a chance to object or ask more questions.
Then the following points need to be made if theij were not already covered by
the clients questions:
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 335

“If at any point something feels uncomfortable or you don’t want to do

something that I asked you to do, just don’t do it. I’ll notice and I won’t
push you into doing it. If I don’t notice, just lift one of your hands to let
me know to back away from a certain body part or a certain way of mov¬
ing it. You can do this exercise sitting comfortably or lying down, just like
with the breathing exercise. Is there anything I need to know about be¬
fore we start? For example, do you have pain in any body part that I
should be aware of?”

This represents another opportunity for the client to ask questions. Once all
questions are answered, the clinician moves on to the basic instructions.

Instructions for Bodily-Awareness Exercise

“Seat yourself comfortably and close your eyes. Draw your attention to
the inside of your body. Consciously focus your mind inside your body
and then just follow my instructions. . . . Remember, you have to do noth¬
ing that does not feel right. ... If you need to signal me to stop some¬
thing I’m asking you to do, just raise one of your hands. As always, let’s
start by taking a deep breath in . . . through the nose . . . and then out. . .
through the mouth.”

Here the clinician takes in a deep audible breath through the nose and then
blows out the breath through the mouth. This may be done a couple of times.

“Breathe in ... “

Clinician inhales audibly.

.. and out through your nose.”

Clinician exhales audibly through the nose.

“And in . . . and out. . . and in . . . and out.”

Clinician establishes a comfortable audible breathing rhythm. This should be

done without speakingfor about twenty to thirty seconds, or whatever period of
time is comfortable for the client. When the client has established a good rhythm
and appears at ease, the clinician moves on to the next set of instructions.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your feet. See if you notice any sensations in your
feet. . . . Now slowly and gently wiggle your toes . . . Pay attention to what
sensations that movement creates in your feet. . . . Notice which muscles
move ... as you wiggle your toes . . . and notice where in the feet you can
perceive the motion in the toes. . . . All the while, keep breathing . . .
gently and calmly, enjoying your focus on your body. . . . When you are
ready, stop wiggling your toes and note the difference in the sensations in
your feet as they once again are still.”
336 CHAPTER ELEVEN

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention up the leg and into your calf. See if you notice
any sensations in your calves . . . your lower legs. . . . Now slowly and
gently flex your feet, keeping your heels on the ground and raising the
toes . . . Pay attention to what sensations that movement creates in your
calves. . . . Notice which muscles move ... as you flex your feet, toes up,
heels down . . . and notice where in the lower legs you can perceive the
motion of your feet. ... All the while, keep breathing . . . gently and
calmly, enjoying this focus on your body. . . . When you are ready, stop
flexing your feet and note the difference in the sensations in your calves
as they once again are still.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention further up the legs and into your knees and
thighs. See if you notice any sensations in your knees and thighs . . . your
upper legs. . .. Now slowly and gently flex your knees, keeping your thighs
on the chair and swinging the lower half of your legs up as high as is com¬
fortable. . . . Pay attention to what sensations that movement creates in
your knees, . . . your thighs. . . . Notice which muscles move ... as you
flex your knees, thighs on the chair, calves and feet in the air . . . and no¬
tice where in the upper legs you can perceive the motion of your lower
legs-All the while, keep breathing . . . gently and calmly, enjoying this
focus on your body. . . . When you are ready, lower your feet and calves
and note the difference in the sensations in your knees and thighs as they
once again are still.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention even further up the legs and into your but¬
tocks. See if you notice any sensations in your buttocks . . . your
bottom-Now slowly and gently flex your thighs and buttocks, squeez¬
ing the buttocks closer toward each other, . . . raising your body a bit with
the power of your muscles in the backs of your thighs. . . . Pay attention
to what sensations that movement creates in your buttocks. . . . Notice
which muscles move ... as you flex your thighs, and squeeze your but¬
tocks togedier. . . . Notice now where in your bottom you can perceive
the motion of your thighs. ... All the while, keep breathing . . . gently
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 337

and calmly, enjoying this focus on your body. . . . When you are ready,
stop flexing your thighs and bottom and note the difference in the sensa¬
tions in your buttocks as they once again are resting in the chair.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and. out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention to your arms and into your hands. See if you
notice any sensations in your hands . . . your fingers. . . . Now slowly and
gently flex your fingers by making a soft fist. . . don’t clench too hard . . .
just curl your fingers toward the palm of your hands. . . . Pay attention to
what sensations that movement creates in your hands and lower arms. . . .
Notice which muscles move ... as you flex your fingers inward . . . toward
your palm . . . and notice where in the hands and lower arms you can
perceive the motion of your fingers. ... All the while, keep breathing . . .
gently and calmly, enjoying this focus on your body. . . . When you are
ready, open your fist and note the difference in the sensations in your
hands and lower arms as they once again are relaxed.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention up the arm and into your upper arm and
shoulder. See if you notice any sensations in your biceps . . . your shoul¬
ders. . . . Now slowly and gently raise your arms overhead, lift your whole
arm straight up in the air.Pay attention to what sensations that move¬
ment creates in your upper arms and shoulders. . . . Notice which
muscles move ... as you hold up your arm, high in the air above your
head . . . and notice where in the arms and shoulders you can perceive
the motion of your arms. ... All the while, keep breathing . . . gently and
calmly, enjoying this focus on your body. . . . When you are ready, lower
your arms and note the difference in the sensations in your upper arms
and shoulders as they once again are resting comfortably at your side.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention further up the body into your neck and throat.
See if you notice any sensations in the small of your neck . . . your
throat. . . . Now slowly and gently turn your head to the right, only as far
as feels good_Chin toward right shoulder-Pay attention to what
sensations that motion creates in your neck and throat. . . . Notice which
muscles move ... as you hold your head to the right, chin above the right
338 CHAPTER ELEVEN

shoulder. . . . Notice where in the neck and throat you can perceive the
turn of your head. . . . Now slowly and gently turn your head to the left,
only as far as feels good . . . chin toward left shoulder. . . . Pay attention
to what sensations that motion creates in your neck and throat. . . . Notice
which muscles move ... as you hold your head to the left, chin above the
left shoulder. . . . Notice where in the neck and throat you can perceive
the turn of your head. ... All the while, keep breathing . . . gently and
calmly, enjoying this focus on your body. . . . When you are ready, turn
your head back to its normal position and note the difference in the
sensations in your neck and throat as they once again return to their
usual place.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

"Now draw your attention up the neck and to your scalp and forehead.
See if you notice any sensations in your scalp . . . your forehead. . . . Now
slowly and gently raise your eyebrows without opening your eyes. . . . Pay
attention to what sensations that movement creates in your forehead and
scalp. . . . Notice which muscles move. . . . Now drop your eyebrows back
down to their usual position . . . and raise them . . . and lower them, re¬
peating this motion a few times, doing it slowly and gently, . . . each time
noticing where in the forehead and scalp you can perceive the motion of
your eyebrows. ... All the while, keep breathing . . . gently and calmly,
enjoying this focus on your body. . . . When you are ready, stop moving
your eyebrows and note the difference in the sensations in your forehead
and scalp as they once again are at rest.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention across the scalp and forehead into your face.
See if you notice any sensations in your eyes . . . your cheeks . . . your
chin. . . . Now slowly and gently open your mouth wide, . . . then slowly
close it, . . . and open it, . . . continuing to open wide and close at a com¬
fortable pace. . . . Pay attention to what sensations that movement creates
in your face. . . . Notice which muscles move ... as you open and'close
your mouth slowly and gently. . . . Notice where in the cheeks, . . . eyes,
and chin you can perceive the motion of your mouth. ... All the while,
keep breathing . . . gently and calmly, enjoying this focus on your body. ...
When you are ready, close your mouth and note the difference in the
sensations in your face and all its features as they once again are at rest.”
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 339

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention down past your chin and throat to your chest
and abdomen. See if you notice any sensations in your chest... . your
stomach. . . . Now slowly and gently take a deep breath, inhale and
exhale . . . deeply . . . slowly, expanding your rib cage as much as you
can. . . . Pay attention to what sensations this deep, . . . deep . . . breath
creates in your abdomen . . . your chest. . . . Notice which muscles
move ... as you inhale . . . and exhale . . . deeply . . . slowly . . . gently. . . .
Notice where in the chest and abdomen you can perceive the rhythm of
your breath, . . . the motion of the air . . . circulating through you. . . .
Keep breathing . . . deeply . . . gently . . . calmly, enjoying this focus on
your body. . . . When you are ready, return to your normal breathing
rhythm and note the sensations in your chest and stomach as they con¬
tinue to move . . . gently now ... up and down.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention to your breath. Take a few moments to observe
the movements and sensations in your body as you breathe . . . in . . .
and out. Enjoying each breath . . . enjoying the clean air it brings to your
body. In . . . and out, . . . in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

“Now that you have observed the movements and sensations in your
body, I’d like you to bring your awareness back to this room. . . . Slowly
begin to focus your attention away from your body . . . away from your
breath . . . and to the outer world. ... Do that by beginning to notice any
sounds that you may hear and when you’re ready go ahead and open your
eyes. Take all the time you need.”

Debriefing of Bodily-Awareness Exercise

The mechanics of the debriefing are virtually the same as those for the basic
breathing exercise. The purpose is merely expanded to include not just the parts
of the body affected by the breath, but also to find out what sensations the client
was able to identify in the entire body. The clinician may want to ask general
340 CHAPTER ELEVEN

questions at first, and then hone in on specific body parts as needed. The more
often the exercise has been repeated, the less intense the querying during the
debriefing will become. The more information a client offers spontaneously,
the less probing the clinician will have to do. Clients can be encouraged to prac¬
tice the body awareness exercise on their own at home. If possible, the mental-
health-care provider makes a tape of the exercise as it was conducted in session
for the client to take home to use for that purpose. In making tapes for clients,
it is best to make tapes the third or fourth time a given exercise was practiced
in session. That way the clinician can make needed modifications after the first
few debriefings. The taped session would then be one that has been altered ac¬
cording to the client’s specifications and that felt comfortable and acceptable
to the client. As recommended above, this encouragement to practice at home
is given as a suggestion, not as a directive.
As implied already, one important aspect of the debriefing is the explora¬
tion as to whether the client had any negative impact from the body awareness
experience. The clinician needs to be careful to point out that a first attempt
does not guarantee success. The clinician and client may need to collaborate to
modify the exercise in a way that is comfortable for the client. For example, if
the client perceived a particular movement as painful, a different motion may
need to be substituted; if the client objects to exploring a particular body part,
a different portion of the body could be covered or the exercise could be short¬
ened. Such small changes can make a tremendous difference with regard to the
perception of the experience by the client and will increase the likelihood that
the client may practice at home. All clients should be given more than one or
two opportunities to try this exercise if they did not appear to benefit from it
the first time. Asking clarifying questions about what worked and did not work
for the client is particularly important in instances when success was low to
moderate. Appropriate alterations can be made until the client is satisfied and
benefits from the experience.

Body Attunement Exercise

This exercise is geared toward more independent recognition of physiological
processes in the client s body. Whereas in the preceding exercise the client was
given help in recognizing what the body feels like by putting it in motion, the
client is now challenged to learn to listen to the body in its natural state. At¬
tention is drawn to various parts of the body and the client is directed to listen
for, watch for, and sense for different sensations that may arise. This exercise
is much more difficult than the awareness exercise, and clients need to have
successfully repeated the awareness exercise before they are introduced to the
attunement exercise. If a client has extreme difficulty with this exercise, the cli¬
nician can return spontaneously to the awareness exercise. Following are the
introduction for the attunement exercise, detailed instructions, and debriefing
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 341

directions. Instructions are once again based on a seated client. All cautions
and comments outlined lor the Bodilij-Awareness Exercise apply to this exer¬
cise as well.

Introduction to Body Attunement Exercise

You know the bodily-awareness exercises we have been doing? Today
I d like to change that a little bit. Rather than telling you to move the dif¬
ferent parts of the body we’ve been paying attention to, I just want you
to observe what they feel like as they are. In other words, listen, watch,
or use whatever sense you can to attend to the parts of the body I’ll men¬
tion. If you feel nothing, that’s fine; there’s no need to panic. Just keep
trying as we move on to the next part of the body. Does that make sense?”

The clinician now gives the client a chance to object or ask questions.

“As always, we’ll start the exercise with the same kind of breathing that
we have been doing and then I’ll ask that you just follow my instructions.
I will ask you to pay attention to different parts of the body at different
times and then I’ll ask you to pay attention to what it is that you are sens¬
ing in that body part. Does that sound okay?”

The clinician gives the client a chance to ask more questions. Then the following
points need to be made if they were not already covered by the client’s questions:

“If at any point something feels uncomfortable, just lift one of your hands
to let me know to back away from a certain body part and I’ll move on.
You can do this exercise sitting comfortably or lying down, just like with
the other body exercise. Is there anything I need to know about before
we start?”

This represen ts yet another opportunity for the client to ask questions. Once all
questions are answered, the clinician moves on to the basic instructions.

Instructions for Body Attunement Exercise

“Seat yourself comfortably and close your eyes. Draw your attention to
the inside of your body. Consciously focus your mind inside your body
and then just follow my instructions. . . . Remember, you don’t have to
endure anything that does not feel right. ... If you need to signal me to
move on to the next body part, just raise your hand. As always, let’s start
by taking a deep breath in . . . through the nose . . . and then out. . .
through the mouth.”

Here the clinician takes in a deep audible breath through the nose and then
bloio.s out the breath through the mouth. This may be done a couple of times.

“Breathe in . . .
 342 CHAPTER ELEVEN

Clinician inhales audibly.

“. . . and out through your nose.”

Clinician exhales audibly through the nose.

“And in . . . and out. . . and in . . . and out.”

Clinician establishes a comfortable audible breathing rhythm. This should be

done without speaking for about twenty to thirty seconds, or whatever period of
time is comfortable for the client. When the client has established a good rhythm
and appears at ease, the clinician moves on to the next set of instructions.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your feet. . . . Just pay attention to your feet and toes. .. .
See if you notice any sensations in your feet. . . . Slowly and gently pay
attention ... to all parts of your feet. . . from your heels ... to your
toes . . . Pay attention to any sensations you might have in your feet. . . .
Maybe they are cold, . . . maybe the toes are touching, . . . maybe there
seems to be nothing at all. . . Just notice your feet, . . . Notice what they
experience, . . . right now ... in this moment, . . . not trying to change
anything, . . . just being aware of what’s there. ... All the while, keep
breathing . . . gently and calmly, enjoying this focus on that very unique
and special part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your lower legs. . . . Just pay attention to your calves and
ankles. . . . See if you notice any sensations in your lower legs. . . . Slowly
and gently pay attention ... to all parts of your lower legs . . . from your
ankles ... to your knees . . . Pay attention to any sensations you might
have in your lower legs-Maybe they are stiff, . . . maybe there’s an
ache, . . . maybe there seems to be nothing at all. . . . Just notice your
lower legs, . . . notice what they experience,. . . right now ... in this mo¬
ment, ... not trying to change anything, ... . just being aware of what’s
there. ... All the while, keep breathing . . . gently and calmly, enjoying
this focus on that very unique and important part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
part of the body. The clinician might want to breathe in and out audibly for a
few breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your upper legs. . . . Just pay attention to your knees
and thighs. . . . See if you notice any sensations in your upper legs.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 343

Slowly and gently pay attention ... to all parts of your upper legs . . .
from your knees ... to your thighs. . . . Pay attention to any sensations
you might have in your upper legs. . . . Maybe they are resting comfort¬
ably on the cushion, . . . maybe there’s a tightness, . . . maybe there seems
to be nothing at all. . . . Just notice your upper legs, . . . notice what they
experience, . . . notice what they feel like to you . . . right now'... in this
moment. . . . All the while, keep breathing . . . gently and calmly, enjoying
your focus on this very important and special part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your buttocks and hips. ... Just pay attention to your
pelvic area. . . . See if you notice any sensations in your buttocks. . . .
Slowly and gently pay attention ... to all parts of your pelvis . . . from
your buttocks ... to your hips. . . . Pay attention to any sensations you
might have in your buttocks or hips. . . . Maybe they are aching, . . .
maybe there’s a sense of ease, . . . maybe there seems to be nothing at
all. . . . Just notice your buttocks, your hips, . . . notice what they experi¬
ence, . . . right now ... in this moment, . . . not trying to change any¬
thing, . . . just being aware of what’s there. ... All the while, keep breath¬
ing . . . gently and calmly, enjoying your focus on this very distinct and
useful part of your body. . . ”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your hands. ... Just pay attention to your fingers and
palms. . . . See if you notice any sensations in your hands. . . . Slowly and
gently pay attention ... to all parts of your hands . . . from the tips of
your fingers ... to the palms ... to the connection with your wrists. . . .
Pay attention to any sensations you might have in your hands. . . . Maybe
they are warm, . . . maybe some fingers are trembling, . . . maybe there
seems to be nothing at all. . . . Just notice your hands, . . . notice what
they experience, . . . right now ... in this moment, . . . not trying to
change anything, . . . just being aware of what’s there. ... All the while,
keep breathing . . . gently and calmly, enjoying your focus on this very
important and amazing part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.
344 CHAPTER ELEVEN

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your arms. . . . Just pay attention to your wrists, . . . your
lower arms, . . . your elbows, . . . your biceps. . . . See if you notice any
sensations in your arms. .. . Slowly and gently pay attention ... to all parts
of your arms . . . from your wrists ... to your elbows ... to your upper
arm. . . . Pay attention to any sensations you might have in your arms. . . .
Maybe they are touching your upper body, . . . maybe there’s a tightness
in the joints, . . . maybe there seems to be nothing at all. . . . Just notice
your arms, . . . notice what they experience, . . . right now ... in this mo¬
ment, . . . not trying to change anything, . . . just being aware of what’s
there. ... All the while, keep breathing . . . gently and calmly, enjoying
your focus on this very miraculous and special part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw your
attention to your shoulders and back. . . . Just pay attention to your shoul¬
ders and upper back. . . . See if you notice any sensations in your upper
back. . . . Slowly and gently pay attention ... to all parts of your shoulders
and upper back . . . from the outside ... to the inside . . . from top . . .
to bottom. . . . Pay attention to any sensations you might have in your
shoulders and upper back. . . . Maybe they are tight, . . . maybe they are
slumping, . . . maybe there seems to be nothing at all. . . . Just notice your
shoulders, . . . notice what they experience, . . . right now ... in diis mo¬
ment, . . . not trying to change anything, . . . just being aware of what’s
there. ... All the while, keep breathing . . . gently and calmly, enjoying
your focus on this very unique and important part of your body. . .

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your throat. . . . Just pay attention to your neck and
throat. . . . See if you notice any sensations in your neck. . . . Slowly and
gently pay attention ... to all parts of your neck . . . from front... to
back . . . inside . . . and outside. . . . Pay attention to any sensations you
might have in your throat and neck. . . . Maybe there’s a lump in your
throat, . . . maybe there’s soreness, . . . maybe there seems to be nothing
at all. . . . Just notice your neck, . . . your throat, . . . notice what they ex¬
perience, . . . right now ... in this moment, . . . not trying to change any¬
thing, . . . just being aware of what’s there. ... All the while, keep breath-
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 345

ing . . . gently and calmly, enjoying your focus on this very distinct and
special part of your body. . .

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your scalp. . . . Just pay attention to your forehead and
the skin covering your head. . . . See if you notice any sensations in your
scalp. . . . Slowly and gently pay attention ... to all parts of your scalp and
forehead . . . from the nape of your neck ... to right above your nose. . . .
Pay attention to any sensations you might have in your scalp and fore¬
head. . . . Maybe there’s tightness, . . . maybe an itch, . . . maybe there
seems to be nothing at all. . . . Just notice your scalp and forehead, . . .
Notice what they experience,. . . right now ... in this moment, . . . not
trying to change anything, . . . just being aware of what’s there. ... All the
while, keep breathing . . . gently and calmly, enjoying your focus on this
very unique and special part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your face.... Just pay attention to your eyes,... nose,. . .
mouth, . . . and chin. . . . See if you notice any sensations in your face. . . .
Slowly and gently pay attention ... to all parts of your face . . . from your
eyes, . . . your nose ... to your cheeks . . . your mouth . . . and your
chin. . . . Pay attention to any sensations you might have in your face. . . .
Maybe the nose hairs are tickling, . . . maybe there’s a trembling, . . .
maybe there seems to be nothing at all. . . . Just notice your face, . . . no¬
tice what all the parts experience, . . . right now ... in this moment,. . .
not trying to change anything, . . . just being aware of what’s there. . . .
All the while, keep breathing . . . gently and calmly, enjoying your focus
on this very important and wondrous part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your chest and abdomen. ... Just pay attention to your
chest area and stomach. . . . See if you notice any sensations in your
torso_Slowly and gently pay attention ... to all parts of your torso . . .
346 CHAPTER ELEVEN

from your chest. . . through your diaphragm ... to your abdomen. . . .

Pay attention to any sensations you might have in your chest and stom¬
ach. . . . Maybe they are warm, . . . there’s a movement,... up and
down, . . . maybe there seems to be nothing of note at all. . . . Just notice
all the parts of your torso,. . . notice what they experience, . . . right
now ... in this moment, . . . not trying to change anything, . . . just being
aware of what’s there. ... All the while, keep breathing . . . gently and
calmly, enjoying your focus on this very crucial and life-giving part of
your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Keeping your attention on your chest and abdomen, . . . slowly and gen¬
tly take a deep breath, inhale and exhale . . . deeply . . . slowly, expanding
your rib cage as much as you can. . . . Pay attention to the sensations of
this deep, . . . deep . . . breath in your abdomen . . . your chest. . . . Notice
all the sensations as muscles move . . . when you inhale . . . and exhale . . .
deeply . . . slowly . . . gently . . . notice the rhythm of your breath in your
chest and abdomen, . . . the motion of the air . . . circulating through
you. . . . Breathing . . . deeply . . . gently . . . calmly, enjoying your focus
on this part of your body. . . . When you are ready, return to your normal
breathing rhythm and note the sensations in your chest and stomach as
they continue to move . . . gently now ... up and down.”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now draw your attention to your breath. Take a few moments to ob¬
serve the movements and feelings in your body as you breathe . . . in . . .
and out. Enjoying each breath . . . enjoying the clean air it brings to your
body. In . . . and out, . . . in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.

“Now that you have observed the sensations in your body, I’d like you
to bring your awareness back to this room.,. . . Slowly begin to focus your
attention away from your body . . . away from your breath . . . and to the
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 347

outer world. ... Do that by beginning to notice any sounds that you may
hear, and when you re ready go ahead and open your eyes. Take all the
time you need.”

Debriefing of Body Attunement Exercise

The mechanics of the debriefing are virtually the same as those for the Bodily-
Awareness Exercise. The focal point is merely shifted to sensations that arose
spontaneously for the client while attending to the various body parts. The cli¬
nician may want to ask general questions at first, and then hone in on specific
body parts. Each body part is addressed during the first debriefing of sensa¬
tions that arose spontaneously. The exercise is the first one that gives the clini¬
cian information about the clients usual physiological state, not a state induced
either through focus on the breath or focus on bodily movements. The more
often the exercise has been repeated, the less intense the querying during the
debriefing will become as the client will spontaneously disclose which body
parts felt something (and what) and which did not. The more information a cli¬
ent offers spontaneously, the less probing the clinician has to do; but the clini¬
cian should keep track to make sure all body parts were covered. Clients can
be encouraged to practice body attunement on their own at home. If possible,
the mental-health-care provider makes a tape of the exercise as it was con¬
ducted in session for the client to take home to use for that purpose, applying
the same cautions provided above. As recommended above, encouragement to
practice at home is given as a suggestion, not as a directive.
The debriefing of this exercise is the most important aspect of the experi¬
ence for the edification of the clinician and the consolidation of inner experi¬
ence for the client. This may be the first time that the client has ever listened
to inner sensations as they arise spontaneously. Often clients are amazed by
what they notice through listening to and watching their bodies. Perhaps for
the first time, they consciously recognize their bodies as vital, sensing, feeling,
and pulsing with life and experience. Clients can be profoundly shaken by this
experience. Other clients may not be affected at all. They may not have been
able to get in touch with many sensations and may not yet perceive the useful¬
ness of the exercise. Persistence is important with such clients, along with en¬
couragement that success is not only likely but imminent. Success may need to
be redefined for such a client as the identification of one single experience in
one body part. The next time the exercise is used, perhaps that will be the first
body part that will be explored, to prime the client for experience. Regardless
of the clients reaction, it is important that the clinician help the client frame
the experience in a positive light and that the clinician can convey optimism
and belief in the power of the exercise in the future. This is true, of course, for
all therapeutic interventions.
348 CHAPTER ELEVEN

Skill Development Recommendations

Recommendation 11-2 Practice the Bodily-Awareness or Body Attune-

ment exercise with a friend or family member. You may want to start by read¬
ing from the script, and then try it from memory. Pick a friend who is willing
to give feedback about your technique. Practice with this person until they
report enjoying the exercise and deriving benefit from it. Then try it with
another friend or family member before using the exercise with a client.

Recommendation 11-3 Make a tape of the exercise for your own use. Prac¬
tice the exercise a few times until you get an appreciation of what it feels like
for the client. If you have a f riend or peer who can guide you through the ex¬
ercise, that may be an acceptable substitute to making a tape. The main idea
is for you to experience the exercise so that you can identify with what your
future clients will go through.

Focus on the Bridge Between Body and Affect

This group of exercises moves the client beyond pure and simple awareness of
physiological sensations and of the body as a whole to a rudimentary integra¬
tion of bodily reactions with emotions. The exercises in this category begin to
tie language used for the expression of emotion to bodily sensations in a subtle
attempt to help clients recognize the connection between physiological sensa¬
tion and emotional experience. These exercises are not yet concerned with
specific labeling of feelings; their main thrust is awareness-raising with regard
to the connection between body and affect. The specifics of affect will be ad¬
dressed once the rudimentary understanding has been developed that affect is
carried and reflected in the body. Once that recognition exists, the clinician will
move the client toward an exploration of how different affective experiences in
the body can be differentiated using a variety of feeling labels.

Basic-Bodily-Experience Exercise
As mentioned previously, this exercise looks surprisingly similar, at least on the
surface, to the Body Attunement Exercise. The critical difference is that the
mental-health-care provider now uses openly emotionally tinged language to
help the client explore the body. At Level Two no attempt is made to tie a par¬
ticular affect to a specific set of sensations in the body. However, if this exercise
is used for higher-level work, this may occur spontaneously and will alter the
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 349

focus of the debriefing used in the exercise. In fact, the debriefing more than
anything differentiates work at different levels. The Basic-Bodily-Experience
Exercise can be used to explore the entire body or can be used in a targeted
manner to single out parts of the body the clinician believes are most relevant
to the clients affective state. The clinician may initially choose to do a whole
body exploration only to hone in on specific smaller parts of the body after an
initial debriefing has suggested that they are most relevant or affected. What
follows are two sample introductions. First, an introduction is given for a client
at Level One who is being exposed to this exercise for the first time. Similari¬
ties to the Body Attunement Exercise can be noted. If the exercise is used with
a client at a higher level, minor modifications are necessary. The main differ¬
ence rests not in the introduction and instructions, but in the debriefing. The
only difference in the introduction is the description of the purpose adapted to
level of work. A sample of a Level Seven introduction is provided to highlight
how this is accomplished. Then instructions are provided for a full-body explo¬
ration of experience. It should be noted that if only a smaller part of the body
is explored (for example, if the clinician notes that the most affected part of the
body is from the shoulders up), much more detailed focus on smaller and smaller
muscle groups can be chosen. The overall-body exercise can be expanded by
adding smaller muscle groups or can be shortened by collapsing some of the
parts of the body into larger groupings. For example, to shorten the exercise,
the legs could be collapsed into one body part to be explored as opposed to dif¬
ferentiating lower and upper; the same could be done for arms. The main cau¬
tion for this exercise rests in the clinicians choice of feeling labels. It is impor¬
tant not to suggest a particular feeling for any one body part. Language is
chosen so as to open the client s mind to a variety of possibilities, not to guide
the client to a specific conclusion about the existence of one particular feeling.
Even if the mental-health-care provider is certain that the client is feeling anx¬
iety (as opposed to depression, anger, and so forth), the range of labels and lan¬
guage used in this exercise needs to encompass all emotions to allow the client
a choice and to expand the client s awareness of the richness and range of hu¬
man affects. To show how the instructions are modified for higher-level work,
an abbreviated Level Seven sample is included. This abbreviation chooses one
body area and shows how the client is directed toward deeper work in the
search for an underlying affect. The same basic deeper work can be translated
to any other body part by the reader, as dictated by client needs. Usually
higher-level work will single out a few specific body parts that have already
been identified by client and mental-health-care provider as most relevant and
affected. It is rare that the entire body will be “exercised” at higher levels of
work. Finally, debriefing directions are provided, first for a Level One client,
then for Level Seven to highlight the differences. All cautions noted so far
again apply to this exercise.
350 CHAPTER ELEVEN

Introduction to Bodily-Experience Exercise: Level One

“You know the body exercises we have been doing? Today I’d like to
change them a little bit again. I still want you to observe what the differ¬
ent parts of the body we’ll focus on feel like, but I’ll also try to give you
some help by every now and then asking you to pay attention to whether
certain feelings may be present. I’ll give you lots of options and I’m never
suggesting that you should feel a certain thing. I am just going to try to
help you explore whether certain feelings fit or don’t fit for you when you
pay attention to different parts of your body. So I’ll ask you to note if a
part may feel relaxed or tense, calm or exited, still or trembling, hot or
cold, good or bad, comfortable or uncomfortable. Just like always, if you
feel nothing, that’s fine; no need to panic. Just pay attention to the next
body part as we move on. Does that make sense?”

The clinician now gives the client a chance to object or ask questions.

“Like always, we’ll start the exercise with the breathing exercise that we
have been doing and then I’ll ask you to just follow my instructions. I will
ask you to pay attention to different parts of the body at different times,
and then I’ll ask you to pay attention to what it is that you are feeling in
that body part. Alright?”

The clinician gives the client a chance to ask more questions. Then the following
points need to be made if they were not already covered by the client’s questions:

“If at any point something feels uncomfortable, just lift one of your hands
to let me know to back away from a certain body part and I’ll move on.
You can do this exercise sitting comfortably or lying down, just like with
the other body exercise. Is there anything I need to know about before
we start?”

This represents yet another opportunity for the client tp ask questions. Once all
questions are answered, the clinician moves on to the basic instructions.

Introduction to Bodily-Experience Exercise: Level Seven

“Do you remember that body exercise we did where I suggested differ¬
ent feeling states while you were paying attention to your body? I think
that exercise would help us figure what else is going on with you emo¬
tionally. Now that we have identified that there is some amount of anxi¬
ety, we both seem to agree that there is more; maybe something deeper.
How about we do that same exercise, but this time I’ll direct your atten¬
tion to move beyond signs of anxiety, to signs of other emotions that may
be there that you didn’t notice before. What do you think?”

The clinician now gives the client a chance to object or ask questions.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 351

“Well then, like always, let’s start with the breathing exercise that you
have been doing and then just follow my instructions. How about you
start with the breathing any time you’re ready, and when you want me to
start with the instructions for the rest of the exercise just raise your hand.
Okay?”

The clinician gives the client control of the breathing exercise as this is ve ry fa¬
miliar by now and the client probably has developed a personal rhythm. No fur¬
ther introduction is necessary. Once the client has found a comfortable breath¬
ing rhythm and has raised a hand to signal the mental-health-care provider to
start, the clinician will move to the instruction portion of the exercise.

Instructions to Basic-Bodily-Experience Exercise: Level One

“Seat yourself comfortably and close your eyes. Draw your attention to
the inside of your body. Consciously focus your mind inside your body
and then just follow my instructions. . . . Remember, you don’t have to
endure anything that does not feel right. ... If you need to signal me to
move on to the next body part, just raise one of your hands. As always,
let’s start by taking a deep breath in . . . through the nose . . . and then
out. . . through the mouth.”

Here the clinician takes in a deep audible breath through the nose and then
blows out the breath through the mouth. This may be done a couple of tunes.

“Breathe in . . . ”

Clinician inhales audibly.

“. . . and out through your nose.”

Clinician exhales audibly through the nose.

“And in . . . and out. . . and in . . . and out.”

Clinician establishes a comfortable audible breathing rhythm. This should be

done without speaking for about twenty to thirty seconds, or whatever period of
time is comfortable for the client. When the client has established a good rhythm
and appears at ease, the clinician moves on to the next set of instructions.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your feet. . . . Pay attention to the feelings in your feet
and toes. . . . Notice the feelings in your feet. . . . Slowly and gently pay
attention ... to all parts of your feet. . . from your heels ... to your
toes_Pay attention to any feelings you might have in your feet-
Maybe they’re cold, ... or warm; . . . maybe they’re cramped; ... or re¬
laxed; . . . maybe they’re moving; ... or still; . . . maybe they’re upset; ...
or at ease;. . . maybe there seems to be no feeling at all. .. . Just notice
352 CHAPTER ELEVEN

the feelings in your feet, . . . Notice what they experience, . . . notice what
they feel like to you, . . . right now ... in this moment. ... All the while,
keep breathing . . . gently and calmly, enjoying your focus on this very
unique and special part of your body. . . .

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your lower legs. . . . Just pay attention to the feelings in
your calves and ankles_Notice the feelings in your lower legs-
Slowly and gently pay attention ... to all parts of your lower legs . . . from
your ankles ... to your knees. . . . Pay attention to any feelings you might
have in your lower legs. . .. Maybe they feel stiff,... or relaxed;... maybe
they’re agitated, ... or calm; . . . maybe they feel heavy, ... or light; . . .
maybe they feel good, ... or bad; ... or maybe there seems to be no feel¬
ing at all. . . . Just notice the feelings in your lower legs,. . . Notice what
they experience,. . . notice what they feel like to you, . . . right now ... in
this moment. ... All the while, keep breathing . . . gently and calmly, en¬
joying your focus on this very unique and important part of your body....”

Clinician gives a slightly longer pause here in anticipation of nwving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your upper legs. . . . Just pay attention to the feelings
in your knees and thighs. . . . Notice any feelings in your upper legs. . . .
Slowly and gently pay attention ... to all parts of your upper legs . . .
from your knees ... to your thighs. . . . Pay attention to any feelings you
might have in your upper legs. ... Maybe they are resting comfortably,...
or uncomfortably; . . . maybe they feel tight, ... or relaxed; . . . maybe
they feel cold, ... or warm; . . . maybe they hurt,... or feel good; ... or
maybe there seems to be no feeling at all. . . . Just notice the feelings in
your upper legs, . . . Notice what they experience, . . . Notice what they
feel like to you . . . right now ... in this moment. . . . All the while, keep
breathing . . . gently and calmly, enjoying your focus on this very impor¬
tant and special part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your buttocks and hips. ... Just pay attention to the
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 353

feelings in your pelvic area. . . . Notice any feelings in your buttocks. . . .

Slowly and gently pay attention ... to all parts of your pelvis . . . from
your buttocks ... to your hips. . . . Pay attention to any feelings you might
have in your buttocks or hips.... Maybe they are aching,... or healthy;...
maybe they have a sense of ease, ... or tension; . . . maybe they are up¬
tight, ... or relaxed; . . . maybe feel heavy and burdened, ... or light and
free; ... or maybe there seems to be no feeling at all. . . . Just notice the
feelings in your buttocks, your hips . . . notice what they experience, . . .
notice what they feel like to you, . . . right now ... in this moment. . . .
All the while, keep breathing . . . gently and calmly, enjoying your focus
on this very distinct and useful part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your hands. . . . Just pay attention to your fingers and
palms. . . . Notice any feelings in your hands. . . . Slowly and gently pay
attention ... to all the feelings in all parts of your hands . . . from the
tips of your fingers ... to the palms ... to the connection with your
wrists. . . . Pay attention to any feelings at all that you might have in your
hands. . . . Maybe they are warm, ... or cold; . . . maybe the fingers are
trembling, ... or still; . . . maybe there is pain, ... or comfort; . . . maybe
they are cramped, ... or relaxed; ... or maybe there seems to be nothing
at all. . . . Just notice the feelings in your hands, . . . notice what they ex¬
perience, . . . notice what they feel like to you, . . . right now ... in this
moment. ... All the while, keep breathing . . . gently and calmly, enjoying
your focus on this very important and amazing part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your arms. . . . Just pay attention to the feelings in your
wrists, . . . your lower arms, . . . your elbows,. . . your biceps. . . . Notice
any feelings in your arms. . . . Slowly and gently pay attention ... to all
parts of your arms . . . from your wrists ... to your elbows ... to your up¬
per arms. . . . Pay attention to any feelings you might have in your
arms. . . . Maybe they are agitated,... or calm; . . . maybe there’s a tight¬
ness in the joints, ... or relaxation;. . . maybe they feel comfortable, . . .
or uncomfortable; . . . maybe they want to move, ... or stay still; ... or
maybe there seems to be no feeling at all. . . . Just notice the feelings in
your arms,. . . notice what they experience, . . . notice what they feel like
354 CHAPTER ELEVEN

to you, . . . right now ... in this moment. . . . All the while, keep breath¬
ing . . . gently and calmly, enjoying your focus on this very miraculous
and special part of your body. . . .”

Clinician gives a slightlij longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your shoulders and back. . . . Just pay attention to the
feelings in your shoulders and upper back. . . . Notice any feelings in your
upper back. . . . Slowly and gently pay attention ... to all parts of your
shoulders and upper back . . . from the outside ... to the inside . . . from
top ... to bottom. . . . Pay attention to any feelings you might have in
your shoulders and upper back. . . . Maybe they are tight, ... or
relaxed; . . . maybe they are down,... or up; . . . maybe they feel heavy
and burdened, ... or light and free; . . . maybe they’re in pain, ... or
comfort; ... or maybe there seems to be no feeling at all. . . . Just notice
your shoulders,. . . notice what they experience, . . . notice what they feel
like to you, . . . right now ... in this moment. ... All the while, keep
breathing . . . gently and calmly, enjoying your focus on this very unique
and important part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your throat. . . . Just pay attention to the feelings in your
neck and throat. . . . Notice any feelings in your neck. . . . Slowly and gen¬
tly pay attention ... to all parts of your neck . . . from front... to
back . . . inside . . . and outside. . . . Pay attention to any feelings you
might have in your throat and neck. . . . Maybe its choked up, ... or
clear; . . . maybe it feels soreness, ... or comfort; . . . maybe it feels heav¬
iness, ... or lightness; . . . maybe there’s tension, ... or relaxation; ... or
maybe there seems to be no feeling at all. . . . Just notice the feelings in
your neck, ... in your throat, . . . notice what they experience, . . . notice
what they feel like to you, . . . right now ... in this moment. ... All the
while, keep breathing . . . gently and calmly, enjoying your focus on this
very distinct and special part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 355

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your scalp. . . . Just pay attention to the feelings in your
forehead and the skin covering your head. . . . Notice any feelings in your
scalp. . . . Slowly and gently pay attention ... to all parts of your scalp and
forehead . . . from the nape of your neck ... to right above your nose. . . .
Pay attention to any feelings you might have in your scalp and forehead....
Maybe they’re tight, ... or relaxed, . . . maybe they carry agitation, ... or
calmness; . . . maybe they hurt, ... or feel no pain; . . . maybe they feel
bad, ... or good; ... or maybe there seems to be no feeling at all. . . . Just
notice the feelings in your scalp and forehead, . . . notice what they expe¬
rience, . . . notice what they feel like to you, . . . right now ... in this mo¬
ment. . . . All the while, keep breathing . . . gently and calmly, enjoying
your focus on this very unique and special part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your face. . . . Just pay attention to the feelings in your
eyes, . . . nose, . . . mouth, . . . and chin. . . . Notice any feelings in your
face. . . . Slowly and gently pay attention ... to all parts of your face . . .
from your eyes, . . . your nose ... to your cheeks . . . your mouth . . . and
your chin. . . . Pay attention to any feelings you might have in die features
of your face. . . . Maybe there is agitation, ... or calmness; . . . maybe
they feel tight and drawn; ... or at ease; . . . maybe there’s trembling, . . .
or stillness; . . . maybe they feel heavy, ... or light; ... or maybe there
seems to be no feeling at all_Just notice the feelings in your face, . . .
notice what all the parts experience, . . . notice what they feel like to
you . . . right now ... in this moment. ... All the while, keep breathing . ..
gently and calmly, enjoying your focus on this very important and won¬
drous part of your body. . . .”

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“As you continue to breathe calmly and in this comfortable way, draw
your attention to your chest and abdomen. . . . Just pay attention to the
feelings in your chest area and stomach. . . . Notice any feelings in your
torso. . . . Slowly and gently pay attention ... to all parts of your torso . . .
from your chest. . . through your diaphragm ... to your abdomen. . . .
Pay attention to any feelings you might have in your chest and stomach.. ..
Maybe they are comfortable, ... or uncomfortable; . . . maybe there is
356 CHAPTER ELEVEN

agitation, ... or relaxation; . . . maybe there is heaviness, ... or light¬

ness; . . . maybe there is upset, ... or ease; ... or maybe there seems to
be no feeling at all_Just notice all the parts of your torso, . . . notice
what they experience, . . . notice what they feel like to you . . . right
now ... in this moment. ... All the while, keep breathing . . . gently and
calmly, enjoying your focus on this very crucial and life-giving part of
your body. ...”
Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician ?night want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Keeping your attention on your chest and abdomen,.. . slowly and gently
take a deep breath, inhale and exhale . . . deeply . . . slowly, expanding
your rib cage as much as you can. . . . Pay attention to the feelings evoked
by this deep, . . . deep . . . breath in your abdomen . . . your chest. . . .
Notice all the feelings as muscles move . . . when you inhale . . . and ex¬
hale . . . deeply . . . slowly . . . gently. . . . Notice the rhythm of your
breath in your chest and abdomen, . . . the motion of the air . . . circulat¬
ing through you. . . . Noticing feelings of calmness, ... or agitation; ... of
tightness, ... or freedom; . . . of lightness,... or burden; . . . of joy, ... or
pain_Breathing . . . deeply . . . gently . . . calmly, enjoying your focus
on this part of your body. . . . When you are ready, return to your normal
breathing rhythm and note the feelings in your chest and stomach as they
continue to move . . . gently now ... up and down.

Clinician gives a slightly longer pause here in anticipation of moving to the next
body part. The clinician might want to breathe in and out audibly for a few
breaths to remind the client to do the same.

“Now bring your attention to your breath. Take a few moments to observe
the movements and feelings in your body as you breathe . . . in . . . and
out. Enjoying each breath . . . enjoying the clean air it brings to your
body. In . . . and out, . . . in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.

“Now that you have observed the feelings in your body, I’d like you
to bring your awareness back to this room. . . . Slowly begin to focus your
attention away from your body . . . away from your breath . . . and to the
outer world. ... Do that by beginning to notice any sounds that you may
hear, and when you’re ready go ahead and open your eyes. Take all the
time you need.”
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 357

Instructions for Basic-Bodily-Experience Exercise: Level Seven

The clinician has received the signal from the client to begin with the instruc¬
tions. Thus, the client has indicated having found a comfortable breathing
rhythm. The clinician starts by moving to the parts of the body that were iden¬
tified previously as housing anxiety (see introduction to Level Seven example).
The purpose is to identify whether any other affects may be hidden in the area.
If the client does not appear to have found a good breathing rhythm ivhen giv¬
ing the signal, the clinician can focus on breathing for a few moments.

“As you continue to breathe calmly and in this comfortable way, begin by
drawing your attention to your torso. . . . Pay attention to the feelings in
your chest area, your back, and your stomach. . . . Notice any feelings
in your torso, no matter . . . how small, no matter . . . how subtle. . . .
Slowly . . . and gently pay attention ... to all parts of your torso. . . . Lis¬
ten to your chest. . . give attention to your diaphragm . . . watch your ab¬
domen . . . and feel your back. . . . Pay attention to any feelings you might
feel in your chest, . . . your diaphragm, . . . your back, . . . and your stom¬
ach. . . . Don’t just notice the familiar feelings . . . the feelings you know
about... of agitation, . . . the butterflies in your stomach, . . . the con¬
striction in your chest, . . . the pain in your lower back, . . . the freezing
of your diaphragm . . . when you hold your breath; . . . Go deeper this
time. . . . Go to unfamiliar ground; . . . notice feelings and sensations that
go beyond the tightness and tension; . . . slowly pay deep . . . and com¬
plete . . . attention ... to every single . . . subtle feeling ... in your torso.
Go beyond the usual, listen for the new. . . . Note if there are deeper feel¬
ings, perhaps .. . of heaviness,... or pain;... discomfort... or unease;...
agitation; ... or doom; ... Go deeper . . . and deeper . . . into your expe¬
rience. . . . Pay closer . . . and closer . . . attention. . . . Note anything, . . .
anything at all, . . . the smallest hint... of feeling. . . . The smallest feel¬
ing . . . of heaviness, . . . agitation, . . . discomfort, . . . pain, . . . confu¬
sion, . . . explosiveness, . . . excitement, . . . joy, . . . pleasure, . . . pain. . . .
Go deeper . . . and listen; ... go deeper . . . and watch; ... go deeper . . .
and taste; . . . go deeper . . . and sense. . . . Sense . . . and feel any¬
thing, . . . anything at all. . . . Notice ail the feelings ... in all the parts of
your torso, . . . notice what they experience, . . . notice what they feel. . .
right now ... in this moment. ... All the while, keep breathing . . . gently
and calmly, enjoying your focus on this very crucial and life-giving part of
your body. . . .”

Clinician gives a long pause here, allowing the client to continue to explore fur¬
ther independently, before moving to the next body part or closing the exercise
with the usual focus on the breath. The clinician might want to breathe in and
out audibly for a few breaths during the pause to remind the client to do the
same. When the client appears done and the exercise should close, or when it is
358 CHAPTER ELEVEN

time to move to the next body part, the clinician moves on. [The sample moves
to a closing; with some clients another set of body parts may be explored fol¬
lowing the example given so far.]

“Now bring your attention to your breath. Take a few moments to ob¬
serve the movements and feelings in your body as you breathe . . . in . . .
and out. Enjoying each breath . . . enjoying the clean air it brings to your
body. In . . . and out, . . . in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“And in . . . and out.

“Now that you have observed the many different feelings in your
body bring your awareness back to this room. . . . Slowly begin to focus
your attention away from your body . . . away from your breath . . . and to
the outer world. ... Do that by beginning to notice any sounds that you
may hear, and when you’re ready go ahead and open your eyes. Take all
the time you need.”

Debriefing of Basic-Bodily-Experience Exercise: Level One

The mechanics of the debriefing are virtually the same as those for the Body
Attunement Exercise. The main difference is that a more feelings-oriented lan¬
guage will be used. The focus will be placed on exploring which body part ap¬
pears to be most readily identifiable as carrying some emotion. It is important
to remember that occasionally, body parts that are involved in the most intense
(perhaps) traumatic experience of the client may have the least feelings associ¬
ated with them. Not uncommonly, for example, clients who are victims of child¬
hood sexual abuse may have little to no sensation in the pelvic/buttock area.
Pushing the client into experiencing something is clearly not the point of these
exercises. Instead they represent a gentle and cautious road to allowing clients
to begin to experience feelings as they emerge, at the client’s pace. If no feel¬
ings are reported within a certain body part, the clinician does not push the cli¬
ent harder next time. This does not mean that the clinician does not inquire
about all experience for all body parts. As always, clinicians ask general ques¬
tions first, and then hone in on all the body parts that were covered in.the ex¬
ercise. Each body part is addressed to gain maximum information about the
client’s current emotional and physiological state. The more often the exercise
has been repeated, the less intense the querying during the debriefing will be¬
come as the client will spontaneously disclose which body parts felt something
(and what) and which did not. The more information a client offers sponta¬
neously, the less probing the clinician has to do. Clients can be encouraged to
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 359

practice bodily experience on their own at home. If possible, the mental-

health-care provider makes a tape of the exercise as it was conducted in session
for the client to take home to use for that purpose, applying the same cautions
provided above. As recommended previously, encouragement to practice at
home is given as a suggestion, not as a directive.
The debriefing of this exercise is a most important aspect of the experience
as this may be the first time that a client has ever listened to inner sensations and
tied them to feeling language. Often clients will spontaneously move to Level
Three work through this exercise, beginning to identify affect and feelings
where they were unable to do so before. This exercise is often a powerful im¬
petus for therapeutic work. With many clients the exercise will not need to be
repeated once they spontaneously move to Level Three work, at least not for
Level Two purposes. Some clients, on the other hand, open up to experience
only if helped by the exercise, and Level Three and Level Two will alternate con¬
sistently until a wide range of affects has been identified. Often when this is the
case, the clinician will find that only relevant parts of the body are covered in
each application of the exercises. The client is the best guide in deciding which
parts of the body to explore to continue gaining awareness and insight.

Debriefing of Bodily-Experience-Exercise: Level Seven

Debriefing at Level Seven (and the other higher levels) is usually quick and easy
as the client is already quite affectively aware and clear about the focus and
purpose of the exercise. Often clients working at a high level will spontaneously
debrief, that is, very little inquiry will be needed. Most importantly, the clini¬
cian needs to help the client recognize the underlying feelings that lurked be¬
yond the readily identified affect that has already been in the client s awareness.
As both client and clinician entered the exercise with that expectation, it is rare
that the client does not emerge from the exercise with some new awareness.
Despite the brevity of the debriefing, this is of course where the thrust of the
therapeutic work takes place. It is in the debriefing that the client clearly
identifies and labels the underlying affect. Work progresses from there.

Advanced-Bodily-Experience Exercise
This exercise makes use of spontaneous expressions of feelings that are not
identified by clients as such. All clients will leak emotions at least occasionally
even when they claim not to be feeling anything or while talking about an is¬
sue. This exercise takes advantage of these emotional leaks, using them to draw
the client s awareness to the body and to sensations and feelings in the body. As
mentioned above, bridge exercises are not yet concerned with labeling a par¬
ticular affect; they merely increase the clients awareness that sensations exist
in the body and that feelings are being experienced all the time, even if they
cannot yet be identified (that is, labeled). Given their nature, bridge exercises
360 CHAPTER ELEVEN

often spontaneously lead to Level Three work as clients often become moti¬
vated to learn labels once they have identified the existence of emotions. This
development needs to be initiated by the client, not the clinician, so as to allow
the client to set the pace for the affective work.
Advanced-bodily-experience work can happen any time and for as long as
necessary. Sometimes it may take moments; sometimes it may preoccupy the
remainder of a session. It is difficult to predict exactly where the work will lead
or how long it will take as these factors depend largely on the openness and re¬
action of the client. This work is extremely useful in that it uses body move¬
ments and sensations that are clearly already finding expression and merely
need to be made conscious to the client. An emotional leak that can be used for
advanced work may consist of a client s gesture, facial expression, or other body
movement while talking (perhaps rather unemotionally) about a certain topic.
A leak is usually obvious to the clinician because of one of several possible traits:

• it is an unusual gesture, expression (facial or voice inflection), or move¬

ment that the clinician has not noted in the client before
• it is a quick gesture, expression, or movement that client tries to hide as
soon as it occurred
• it is a gesture, expression, or movement that occurs with some regularity,
always in a predictable context
. it is a habitual gesture, expression, or movement that the client does not
appear to be aware of and may even deny if asked about

Once the leak has occurred, the clinician asks the client to repeat it. Some¬
times clients are confused when asked to repeat a certain gesture or move¬
ment, as they were not even aware that they engaged in it. The clinician can
simply ask such clients to repeat what they said exactly as they said it and to pay
attention to their bodies. Clients will then generally repeat and become aware
ol the movement. If this procedure does not work, it is best to drop the issue
and to try again when the next leak occurs. Sometimes, clients may deny the ges¬
ture as they appear to be embarrassed by it. The mental-health-care provider
then has to make a judgment call as to whether it is worth pushing the issue. A
good rule of thumb is that if rapport is secure and the client seems to trust the
clinician, it may be worth pursuing the work on the leak. If rapport is still be¬
ing built or the client feels vulnerable vis-a-vis the clinician, it will not be worth
the risks to pursue the issue. Clearly, the faster the clinician can catch the leak
and draw the clients attention to it, the more likely the client will not be able
to deny or forget it.
If the leak was caught quickly and the client repeats the gesture or move¬
ment upon the request of the clinician, she or he is then asked to talk about the
bodily expression. Most specifically, clients will be asked what thoughts the
movement or gesture evokes, if it is familiar, used often, used by anyone else
they know, and what else comes to mind as they engage in the movement again.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 361

Cautious query about accompanying internal bodily experiences can also be

useful. If the client can identify physiological reactions, that can be helpful as
well. The exercise can also involve asking the client to exaggerate the motion
or gesture. With many clients, simple repetition may not have enough impact
to help them recognize the emotional expression and experience contained
within the movement. Asking the client to exaggerate the motion will increase
its emotional salience and may help the client to recognize the underlying ex¬
perience. Exaggeration is more likely used with clients at lower levels; simple
repetition often suffices at higher levels as clients are already more self-aware.
Stopping clients and asking them to become aware of the bodily experi¬
ences they have as they speak has the same effect as the basic bodily experience
in that it draws their attention to bodily processes and to the fact that feelings
may be lurking under behavior and thought. The advanced exercise is best un¬
derstood by example. Hence what follows are two examples. The first example
shows an application of the exercise with a client who is working at Level Two,
that is, a client who is still struggling with basic inner experience and is not yet
labeling affect. This example will show the application of the exercise with a re¬
quest for exaggeration of die movement. The second example is applied to
Level Six, involving a client who is beginning to recognize the fact that emo¬
tions do not necessarily exist singly, but can be mixed across emotional cate¬
gories. Simple repetition (that is, no request for exaggeration) will be demon¬
strated here.

Level Two Application of the

Advanced-Bodily-Experience Exercise
This example involves a client who is seen in her fourth session, and who was
relating an incident that occurred between her and a close female friend. The
client and diis particular friend have been fighting frequently and yet have re¬
mained friends for many years. The client is currently considering breaking off
the friendship, in part motivated by the friend s recent announcement that she
has discovered that she is gay. The client is showing a lot of affect about her re¬
lationship with this friend and her decision making regarding what to do about
the friendship. Nevertheless, her voice remained somewhat monotone, though
some inflections were notable, suggesting that feelings were just under the sur¬
face. In prior sessions the client had denied feeling any particular feelings
about anyone in general, and about this friend in particular. She indicated that
her family of origin was not very “emotional” or “touchy-feely” and that she did
not believe in “making too much of feelings.” Thus, the client appeared some¬
what closed off from her feelings and seemed to have only occasional aware¬
ness of emotionality. This occasional awareness led the clinician to the conclu¬
sion that the client was currently struggling affectively somewhere around
Level Two or Three, having some rudimentary awareness (or an inkling of ex¬
perience), but not being quite able to label feelings because of not accepting
362 CHAPTER ELEVEN

affect as an important aspect of being human. While talking about the interac¬
tion with her friend, the client crossed her legs (a seated position she had not
assumed before) and swung her lower leg rhythmically and quite forcefully.
When she stopped talking, she returned to her usual position, which consisted
of sitting back in the chair, legs (touching each other) side-by-side and both feet
on the ground. The following interchange was then initiated by the clinician:

clinician: Would you sit back the way you were sitting just a minute ago?
CLIENT: Sit how? (looks puzzled)
clinician: With your legs crossed like that (models the position) and
your leg swinging. . . .
CLIENT: Why?
clinician: I’d like to try something with you. . . .
CLIENT: Like that? (shifts to the “leak” position)
clinician: Yeah, that was it. Now swing your lower leg, like that, (models)
CLIENT: I really did that?
CLINICIAN: Yes, you really did.
CLIENT: Okay, so now what? (swinging her leg)
CLINICIAN: When you were sitting like that you were talking about
telling Amy that you would like to end the friendship. I got the feeling
that you were communicating something else to her with the way you
were holding your body. So I thought maybe you could sit like that again
and listen to your body. See if you can identify any sensations you are
aware of as you sit that way. . . .
CLIENT: Okay. . . .
CLINICIAN: Go ahead and start swinging your leg, like you did before.
CLIENT: (complies)
clinician: What do you notice in your body?
CLIENT: I don’t know . . . (tentative and unsure)
clinician: Hang in there with me for a moment. I really think this will
help us out. Would you, just to give this a fair try, swing your leg a little
harder?
CLIENT: Swing harder?
clinician: Yea, just put a little more “umph” in that movement.
CLIENT: Okay . . . (grins and swings harder)
clinician: Okay, now what do you notice in your body?
client: I’m not sure, but it seems like the right thing to do when I think
about Amy right now. (more forceful voice now)
clinician: What feels right about it?
CLIENT: Well, it gives me something to do I guess, (backs off the affect)
It occupies me with something because this is a tough thing to do, you
know, to tell your friend you want out.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 363

CLINICIAN: What thoughts come to mind as you do it, as you swing your
leg? (allotting the detour away from obvious affect for now and going to
the cognitive plane, which is more comfortable for the client)
CLIENT: Oh, I got it; it’s like—“Hey Amy, I really wanna kick you out
right now!”
CLINICIAN: Were you aware of that thought before?
CLIENT: No. But you know what, it’s true. I would like to kick her.
(rather emphatic now; more voice inflection than before) How can she do
this to me. Gay? Since when? Next thing she’ll wanna be lovers.
CLINICIAN: You really are having a reaction to this.
CLIENT: Yes, I am. I guess I didn’t realize how upset I was about this
whole thing. Is that it? I’m swinging my leg to kick her because I’m upset?
CLINICIAN: Is that what you make of it?
CLIENT: Yeah. I am. I am upset. My body is upset. I can feel it in my
stomach now. Wow, all that from swinging my leg. (Client moves back to
her usual position now, needing to gain some distance.) (Session continues
from here.)

This example shows how a simple exaggeration of a movement helped the

client achieve a recognition of a bodily experience or impulse that moved her
along the continuum of affective awareness. The fact that she labeled the anger
reflected in the swing as “upset” is not important. The label at this point is
much less critical than her recognition that she was having a physical reaction
to the situation. The session moved from there to more exploration about her
relationship with Amy and some work around her beliefs about homosexuality.
The client stayed away from affect for the remainder of this session but seemed
touched by the experience.

Level Six Application of the

Advanced-Bodily-Experience Exercise
This example involves a client who has been seen for twelve sessions. At this
particular moment the client was talking about his anger in his relationship with
his wife, when he suddenly wiped his eyes and quickly turned his head away
from the clinician. The client continued to talk angrily and acted as if he him¬
self had not been aware of this brief glimpse of another emotion. The clinician,
knowing that rapport was solid, decided to interrupt the client to draw his at¬
tention to this emotional leak and an exploration of its potential meaning.

CLIENT: . . . and as always it just pissed me off. (The “leak” gesture oc¬
curs.) Well, I should say it aggravated me, because it wasn’t really as bad
as being pissed off. . . .
CLINICIAN: (interrupting) What was that?
CLIENT: What was what?
364 CHAPTER ELEVEN

CLINICIAN: That thing you just did with your hand!

CLIENT: Nothing. . . .
CLINICIAN: Nothing?!
CLIENT: Well, I don’t know. . . .
CLINICIAN: What do you think. . . . Given all the work we’ve done paying

attention to how you use your body to express your feelings, do you really
think it was nothing?
CLIENT: I’m not even sure what you’re talking about.

CLINICIAN: I’m talking about that thing you did with your hand and your
head right when you changed your mind about how angry you were.
CLIENT: What did I do?
clinician: This, (models the head turn and eye wipe) You do it. What
do you feel when you do that?
CLIENT: (wipes eyes and turns head; remains silent, but looks struck)

clinician: What’s going on? (very gentle voice, leaning forward)

CLIENT: It’s like I’m crying, isn’t it?
clinician: (nods gently, stays leaning forward) What’s that about?

CLIENT: I’m not one to cry . . . but I think of sadness right now. . . .
CLINICIAN: You’re thinking of sadness. . . .
CLIENT: Yes, I’m sad. (voice mirrors the sadness and also betrays some
surprise at this recognition) So much has gone wrong between me and
Charlotte. But we used to love each other so much. It’s so sad to be
fighting.
clinician: So aggravation isn’t all there is. . . .
CLIENT: I guess not. I thought I was just mad, but it’s really sad too, isn’t
it? We have twenty-three years in that relationship. We should be willing
to fight for it, don’t you think?
CLINICIAN: What do you want to do? Do you want to fight for it?
(Session continues from here.)

This example shows how a very quick and easily missed gesture can open
the door to new awareness and inner experience. This client, who had just
learned to recognize the varying degrees of his own anger, had never recog¬
nized his sadness about the changes in his spousal relationship before. The ges¬
ture gave the clinician an opening to invite the client to recognize that he felt
more than anger. Interruptions are of course not always a good idea. However,
in this case the clinician knew the client well and felt that the current-task of
affective work was to help the client recognize his mixed emotions. Thus, the
opportunity needed to be seized. The client not only recognized his anger but
also came to experience his sadness, a profound step in the direction of recog¬
nizing and ultimately accepting mixed emotions about the same situation. The
whole process only took moments and yet the therapeutic accomplishment was
 WORKING WITH AFFECT AND EMOTION: FOCUS ON THE BODY 365

Skill Development Recommendations

Recommendation 11-4 Practice the Bodily-Experience Exercise: Level

One with a friend or family member. You may want to start by reading from
the script, and then try it from memory. Pick a friend who is willing to give
feedback about your technique. Practice with this person until they report en¬
joying the exercise and deriving benefit from it. Then try it with another
friend or family member before using the exercise with a client.

Recommendation 11-5 Make a tape of the Level One exercise for your
own use. Practice the exercise a few times until you get an appreciation of
what it feels like for the client. If you have a friend or peer who can guide you
through the exercise, that may be an acceptable substitute to making a tape.
The main idea is for you to experience the exercise so that you can identify
with what your future clients will go through.

relatively large. Feeling words were very appropriate with the client as he was
already somewhat emotionally sophisticated. He was able to identify a range of
affects, was clearly aware of differing levels of intensity at least with regard to
anger, and thus was ready to move to Level Six, recognizing and integrating the
experience of more than one emotion at a time.
Working with Affect
and Emotion

Focus on Feelings

People hate the darkness of their negative tendencies

just as children hate the darkness of the night, but
just as if there were no dark of night we would never
recognize the light of day, so also if we possessed no
negative aspects we could never recognize our positive
ones. Our negative and positive tendencies are thus the
valleys and the mountains of a beautiful landscape—
there can be no mountains without valleys, and vice
versa, so that those who would misguidedly seek to
annihilate the valleys must in the same stroke level
the mountains. Trying to rid ourselves of negative
tendencies, trying to destroy them and eliminate them,
would be a fine idea—if it were possible. The problem
is, that it is not, that the negative tendencies in
ourselves to which we try to shut our eyes nevertheless
remain firmly ours and return to plague us as neurotic
symptoms of fear, depression, and anxiety. Cut off from
consciousness, they assume menacing aspects till out
of proportion to their actual nature. We can tame evil
only by befriending it, and we simply inflame it by
alienating it.
K. Wilber, 1993, p. 196

This chapter continues the work with affect and emotion by focusing on strate¬
gies that help clients explore their full range of affects, including subtle nu¬
ances of affected, blended feelings, underlying emotions, and their meanings.
In the previous chapter, work with the body was used to help clients recognize
and gain awareness of their affects and emotions. In this chapter, bodywork is
largely used to help clients gain a sense of mastery over their affect and recog¬
nize that they need not be victims of their emotions. Overall, the focus of the
366
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 367

exercises in this chapter is on helping clients become more sophisticated in

their affective experience, teaching them higher levels of affective awareness.
As such, the work focuses on helping clients recognize the higher-level affec¬
tive nuances contained in subtle blends of emotions, coexisting emotions, and
underlying affects. It seeks to help clients accept all of their emotions, both
positive and negative, and to recognize their meaning and source.
Many examples and instruction are included to help the clinician apply this
work directly with clients. As in the prior chapter, in these samples and in¬
structions words that are spoken by the mental-health-care provider directly to
the client are placed in quotation marks and blocked format. These words need
to be spoken in a well-paced manner. It is better to go too slow than too fast.
Some practice may be required here to get the pacing just right. Ellipses, that
is, three periods (...), indicate places where the clinician best pauses for a mo¬
ment before moving on. The length of the pause will need to be adjusted as the
clinician becomes familiar with a given client’s needs. Actions the clinician takes
while practicing a particular exercise with the client are printed in italics. Ba¬
sic comments and instructions to the mental-health-care provider are printed
in regular typeface. Any directions that need to be tailored to a client’s particu¬
lar affect or body area are placed in [brackets]. The content in the bracket will
consist either of an example or a directive as to what to fill in the bracket. None
of the instructions (including introductions and debriefings) have to be used
verbatim. All transcripts are simply examples and reflect the content that needs
to be covered; how this is accomplished will be up to each individual mental-
health-care provider. It is best not to work from a transcript while with the cli¬
ent, even during exercises for which the client closes the eyes. The rustling of
paper can be distracting and the pacing is often not as attuned as when the cli¬
nician speaks from memory. Although this may seem overwhelming at first,
none of the scripts is actually very difficult. Memorizing the gist of each is usu¬
ally pretty easy and just takes a little bit of practice.

Focus on the Experience

and Identification of Affect

The exercises in this category are designed to help clients distinguish different
affects and to recognize that the same affect may occur with varying intensities
in different situations or even within one and the same situation. Both exercises
help clients integrate experience with language, being concerned not only with
the inner experience of affect, but also the outer labeling (or verbal expression).
This outer labeling helps clients recognize that there are many affects and in¬
tensities and gives them an invaluable tool of communication. Identification and
labeling also increase affective awareness, the most important aspect of this
368 CHAPTER TWELVE

work. It is crucial to understand that the experience is always more important

than the label. If a client is clear about the experience but cannot settle on a spe¬
cific label, that is no problem. Too often clients jump to the use of labels when
the label really does not reflect experience. It is much better to have the client
render a description of the physiological reaction and processes than to be pre¬
sented with a beautiful label. The idea of labeling is introduced because it is
useful for communication and over time can turn into a shortcut for client and
clinician in terms of talking about what the client is feeling. The label must not
be abused as a substitute for experience. This caution, while most relevant here,
applies to all affective work. A final note of caution about labeling affect may
be indicated. Clinicians can provide samples of labels but they do not choose la¬
bels for clients. The final choice about how to label an internal experience al¬
ways rests with the client, even if the clinician does not agree with the client s
choice. Thus, if a client chooses the word “gloomy” for an affect the clinician
would have labeled “defeated,” the client s label will be used to talk about the
particular experience from now on. The clinician and the client will both know
what the label stands for, that is, both are clear about the physiological sensa¬
tion the label “gloomy” describes. Squabbling over which label “fits better” is
irrelevant as all language is relative in any event.
Although only two formal exercises are noted here that deal with or focus
on affect, there are numerous therapeutic interventions that can be used to
help clients with these same goals. Further, the two exercises covered here are
anything but static. They will look different with each client and with each ap¬
plication. Thus, unlike for the exercises covered up to this point, only general
directions and examples can be given, no firm outlines or instructions as to
what exactly has to be done. These are not step-by-step exercises as much as
they are therapeutic interactions that have a clear direction but a meandering
path toward their final goal(s). It probably goes without saying that use of these
interventions requires affective self-awareness on the part of the clinician. Fur¬
ther, to be successful in helping clients recognize the distinctions between feel¬
ings (as in mixed emotions) and within feelings (that is, in levels of intensity)
based on the inner experience and bodily sensations that accompany them, cli¬
nicians need to have a large affective vocabulary. There are many common la¬
bels for feelings that have been so overused that clients may reject them for the
simple reason that they ring trite or commonplace. Further, there are many af¬
fects that are often stereotyped to a single label (for example, happy, depressed).
It may be helpful in differentiating levels of intensity to have a large set of syn¬
onyms. To help clinicians develop an affective vocabulary, Table 12-1 lists feel¬
ing words that can be used for work with clients at basically all but the very low¬
est levels of affective experience. This listing is by no means all-inclusive but
represents an attempt at compiling a useful listing of the many feeling words
that exist. Clinicians are encouraged to add to the list on an ongoing basis.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 369

Here-and-Now Affect Exploration Exercise

The goal of this exercise is to help clients translate inner affective experience
into the recognition of emotion and the selection of a label for it. It enriches and
enhances the work that was done up to this point by challenging clients not only
to listen to their bodily experiences and feelings, but also to begin to recognize
what each sensation and feeling may represent. Here-and-now work is used at
Level Three for the first time, and is used consistently from here on out in the
therapeutic process. In fact, most clients will benefit from here-and-now work
regardless of the level of affective experience they have Achieved. All here-and-
now work is based on an affective experience that occurs during the session,
that is, is focused on an affect the clinician perceives in the client, but of which
the client appears unaware. The purpose of here-and-now work is adapted to
the client s level of affective experience as identified by the clinician, and shown
in Table 11-1, but in all cases the ultimate goal is to help clients recognize their
emotional state empathically and accurately. What follows are discussions and
examples of the application of here-and-now work at two different levels of af¬
fective experience.
In reading this information, it is important to keep in mind that clients who
function at Level Three and higher may be unconsciously selective in their un¬
awareness, unlike clients who are in need of the Level One and Two interven¬
tions. Some clients may be quite aware of their positive affects but have no
awareness of negative affects. Thus, they function at different levels in differ¬
ent areas of emotionality. Further, they may have very differentiated experi¬
ence when it comes to some emotions, but all-or-nothing attitudes about others.
For example, a client may be exquisitely sensitive to varying levels of happiness,
but perceive anger as rage regardless of intensity. This again represents a cli¬
ent who functions at different levels of affective experience with regard to dif¬
fering emotions. Here-and-now work can be sensitive to working with clients
on varying levels depending on which affect is being dealt with. In all here-and-
now work, the clinician keeps in mind that clients lack affective awareness for
many reasons. Often understanding the reasons behind the clients affective
states helps the clinician tailor treatment, even when the work with the client
does not yet address the understanding and acceptance of affect that occurs at
Level Seven and Eight. Some possible reasons for lack of awareness follow.
This list is not all-inclusive, but should give the clinician food for thought as to
where to look.
Possible Reasons for Low Affective Awareness and Experience
. client learned in childhood not to pay attention to affective arousal
because the client s affective needs remained unmet
. client had a traumatic experience at some time during the lifespan and
subsequently repressed all or certain affects
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372 CHAPTER TWELVE

• client grew up in a nonresponsive environment and never learned about

affects
• client was raised with a focus on cognition and/or behavior and never
integrated affect into the human experience
• client was punished for the expression of certain or all affects in
childhood
• client was ignored when expressing certain or all affects in childhood
• client had little guidance during childhood about emotions and their
meanings or labels
• client learned little or nothing about expressing and labeling affect as a
means of diffusing it
• client did not learn that expressing and labeling affect is a normal part of
psychological growth and health

Level Three Here-and-Now Work

At this level, mental-health-care providers focus on helping clients begin to
recognize the existence of basic affects by drawing their attention to bodily sen¬
sations and changes as feelings arise in the therapy room. Clinicians can rec¬
ognize Level Three when clients express an affect without being aware of it or
talk unemotionally about a situation that would usually arouse affect. When this
occurs, the clinician has a perfect opening for here-and-now work that directs
the client to sensations or feelings in the body. This here-and-now work will put
the client in touch with bodily sensations that were previously ignored and that
are clearly tied to affective experience. The client will then be encouraged to
come up with a label for the feeling that is being recognized, although this la¬
beling often occurs spontaneously. As this kind of work is best learned through
example, an interchange follows that models it. In the following example, the
client is relating an incident that is highly suggestive of an emotional reaction,
but does so without any emotional expression. The clinician intervenes to help
the client recognize his underlying affect.

CLIENT: Funny thing happened this week at work. We had a hold-up.

(grins oddly)
clinician: A hold-up?! (expression of emotion intended)
CLIENT: Yup. . . . (matter-of-fact voice, but eyes wide, betraying some
emotion )
clinician: Tell me about it! (voice still intense to model)
CLIENT: Well, I was working the night shift; you know they always joke
about us night clerks at convenience stores taking our lives into our
hands. But I really never thought about it. Anyway ... I was working the
night shift, and it was pretty quiet so I think I wasn’t really paying much
attention to what was going on. Don’t tell anyone, but I may have nodded
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 373

off. ... So this guy suddenly stands in front of me with a gun pointed at
my chest, (grins and pauses)
CLINICIAN: Oh . . . (leaning forward; intensely attentive)
CLIENT: Well, it was just like in the movies—He told me to clean out
the cash register for him, then he wanted some booze, and cigarettes. We
keep those behind the counter, you know. I guess that’s why he asked me
for those because then he just started grabbing stuff off the shelves. He
was just having a ball.
CLINICIAN: And you?!
CLIENT: Well, I was just watching him. I didn’t really know what to do.
And then all of sudden he got pissed, started yelling at me for watching
him, telling me to lie down on the floor or he’s going to shoot. He was
waving his gun at me again. I dropped to the floor and then all hell broke
loose. I guess something I did just really pissed him off. He started trash¬
ing the place, throwing stuff, pushing shelves over. I couldn’t see what
was going on anymore, and it got to be really something when he started
shooting his gun off. I have no idea what he was shooting at, I just was
waiting for it to be me. . . . (voice raised, agitated now)
clinician: How awful.
CLIENT: Oh well, (shrugs; looks away; trying to shut down the affect that
was beginning to emerge)
CLINICIAN: Then what?
CLIENT: I think he finally ran out of bullets, so he starts screaming at me
again to get up and bring him that booze, (very pale now; voice highly
pitched)
CLINICIAN: And?
CLIENT: I got up and there he is right in front of me with this huge
blade. I thought for sure he’d slice me right there and then, (takes deep
breath)
CLINICIAN: Uh huh . . .
CLIENT: And then, right then, a cop walks in. Can you believe it? I coulda
kissed the guy. He totally clued into what was going on and had the guy
down in a flash! I gotta go to the station tomorrow again to talk to them
some more. I’m not sure why. (voice getting lower and more agitated)
CLINICIAN: Wow, incredible. So much going on. . . .
client: Tell me about it! (flushed now)
CLINICIAN: Tell me what is going on with you right now?
CLIENT: What?
CLINICIAN: What are you feeling right now?
CLIENT: Nothing much, I guess, (tries to pull back from his experience)
CLINICIAN: Look at you—You’re at the edge of your seat, your face is
flushed, and I don’t think I’ve ever heard you more upset.
374 CHAPTER TWELVE

CLIENT: Well, the cop even said that I was pretty cool about it all. You
know, I’m no wimp. No stupid little crook is gonna spook me. . . .
CLINICIAN: So what would you say is going on in your body right now?
Tune in a little bit. What can you sense right now?
CLIENT: My face feels hot. My heart is feeling funny; I guess you’d call
it my heart is racing—you know, like it’s on speed or something. And you
know what, I didn’t really put this together before, but my stomach’s
been upset ever since. It’s like cramping all the time and I don’t have
much of a craving for food. Oh, and I don’t know if that has anything to
with it, but you know those blood pressure machines at the grocery
store? I always use it while I wait for my take-out. Well, today it was like
totally off the chart. . . (pauses; looks up) What do you think?
CLINICIAN: More importantly, what do you think? Or more to the point,
what’s your body telling you?
CLIENT: I guess I’m a little freaked out maybe? I haven’t slept too well
the last couple of nights, so maybe I’m just a little run-down. I don’t
know . . . (calming down now)
clinician: Would it make sense to be a little freaked out?
client: I suppose so. I guess I might have actually been pretty scared
while it was going down. Just kept telling myself these guys can smell
fear, so don’t be scared. But I don’t know. .. .
CLINICIAN: You don’t know?
CLIENT: Well, you know. I think maybe I was scared but then I’m not
sure. I was raised to be tough. You know that. My father the drill
sergeant, (grins)
clinician: Yeah, I know that. But what you were feeling a minute ago,
that was real!
CLIENT: I guess so. . . .
clinician: And you called it being freaked out... or scared. Was it any¬
thing like what you felt that night?
CLIENT: Oh yeah. I was actually getting a little freaked here because I
got to where it was like I was back there, you know, feeling it all over
again.
CLINICIAN: Sure, that makes sense!
CLIENT: It does? (puzzled) Why would I get scared now? It’s over and
done with.
CLINICIAN: It may be over and done with, but the feelings, those can
linger; especially since you didn’t really pay attention to them at the time.
(Session goes on from here.)

This example shows how even a client who has blocked his emotions suc¬
cessfully for a long time can be led to recognize feelings. Every human being has
a physiological response in situations that are emotionally arousing or stimulat-
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 375

ing. In fact, if a situation was grave enough, as the one this client was relating,
just the telhng of the story should result in the same physiological arousal. If the
mental-health-care provider can help the client identify that physiological re¬
sponse by drawing attention to the bodily reactions in the here-and-now, the cli¬
ent may learn a valuable lesson about how to recognize and identify emotions.
In the example, the emotion involved became fairly obvious once the client re¬
alized that he indeed had a feeling response to the situation he was talking
about, both at the time of the event and right now. Once the client acknowl¬
edged his present arousal (his physical sensations), he spontaneously recog¬
nized it as fear (again in both situations), a perfectly normal response given the
situation he had found himself in. This recognition and admission of fear was a
breakthrough for this client, who had been very divorced from his feelings up
to now. No doubt, the body awareness and breathing exercises had primed him
to be more in tune with his body so that the recognition of affect, and its sub¬
sequent labeling, were allowed to happen now.

Level Seven Here-and-Now Work

Here-and-now work at Level Seven (that is, work on identifying underlying
emotions) is highly sophisticated work with clients who are already very emo¬
tionally aware and savvy. The work at this level challenges clients to look deeper
and to explore levels of experience that may be buried and not easily reached.
This work is often not done until a client has been in treatment for a while or
is done with a client who comes to treatment without major developmental de¬
lays but primarily for personal growth. The goal of the here-and-now work with
the Level Seven client is to help the client identify underlying affects, or affects
that are at the root of the clients adjustment and behavior. These affects are
buried under more obvious and easily experienced or accepted affects, and of¬
ten their recognition moves the client forward in treatment. Many times when
clients become aware of underlying affects, they spontaneously move to insights
about themselves that they did not have before, making connections about
their emotional life that they had been unclear about until now. Following is an
example of Level Seven here-and-now work that leads to such insight. The ex¬
ample clarifies how such work can lead to spontaneous understanding of the
origins of certain behaviors or emotions, essentially leading the client to Level
Nine work. The example is taken from the beginning of the client’s fourteenth
session.

CLIENT: (client plops down on the couch and immediately starts talking
without needing clinician encouragement) I am so pissed I could scream!
(clearly agitated, flushed face, loud voice) You would not believe what just
happened! Unbelievable! I just got fired. The gall of that woman to kick
me out. ME, of all the people in that office. I gave the best ten years of
my life to her!! I’ve been loyal; I’ve been there when she was having
376 CHAPTER TWELVE

problems—and now this. I am so pissed. No, pissed doesn’t even cover

it. I am furious!! I don’t think I’ve ever been this mad in my life. Can you
believe this? (takes a breath and pauses for a brief moment)
CLINICIAN: Wow, what a development! You’ve been talking about prob¬
lems at work, but how did this come about?
CLIENT: Well, I got there early this morning. You know how I like to be
early. You know, how I like to get there before everyone else and get or¬
ganized for the day. And there she was, passed out on the floor, booze all
over the place.
CLINICIAN: She?
CLIENT: Oh, sorry, my boss, you know, Karyn. (calming and slowing
down a bit now) Well, I think I told you that I have been suspecting that
she is a boozer, but I guess I don’t have to suspect anymore. This was
pretty clear evidence. She was passed out good and I wasn’t sure what to
do. So I decided to go to my desk and pretend she’s not there. So I did
that for a while and then I got worried and so I went back over there and
she was still on the floor but it looked like she was awake. So I said “Karyn,
I think it’s time to get up and get cleaned up. You look like a mess.” She
just stared at me like she couldn’t process what I was saying and then she
groaned and started throwing up. So I went and got a garbage can to try
to keep some of this crap off the floor because I sure as hell didn’t want
to have to clean it up. Is this disgusting or what. I really started getting
pissed then. You know, if she wants to be a lush, fine. But leave me out of
it. She knows I come in early so did she have to be there when I got
there? I was getting really pissed and I started yelling at her to pull her¬
self together. I tried to get her to get up and go to the bathroom and
finally she did. Of course she left her mess behind, probably expecting
me to clean up after her. I tell you what though—no way in hell! I heard
her retching in the bathroom for a long time and then when she came out
she was white as a ghost. She looked at me like it was my fault and told
me to get lost. Told me to get lost! Can you believe it? I said where do
you want me to go. And she said to go for a walk or something till it was
time to go to work. Then she started yelling why was I early and was I
checking up on her. Paranoid stuff, you know. Well, I told her I wasn’t
gonna leave, but that she should. I also told her I’d have to tell Carl.
CLINICIAN: Carl?
CLIENT: Her boss . . .
CLINICIAN: Ah . . .
CLIENT: Boy, that really got her going. She said it was none of my busi¬
ness what she did after hours and I told her it was if she did it in my work
space. I guess I was a little out of line because it’s really her work space,
but still. . . . Anyway, I refused to leave, told her I had a lot of work and I
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 377

wasn’t gonna get behind because of her drinking. I was steaming by then.
You know what a hothead I am anyway. Well, we ended up in a shouting
match and neither one of us had any intention of backing down. I kind of
forgot who’s the boss, I guess. Anyway before I knew it, she told me that
was it for me. Fired. She’s the screwup and I’m unemployed. I went to see
Carl as soon as I could, and he refused to listen. Said something about
women not being able to work together! You can imagine that that didn’t
exactly help my mood. So I ended up yelling at him, too, and threatening
to sue the company. He threw me out of his office. Threatened to call se¬
curity. God, I was screaming mad. I am so glad I had an appointment at
lunch with you today because I don’t what I would do if I couldn’t get this
off my chest. If ever I had a murderous impulse, this would be the time.
(grins a little) Na, don’t worry, just kidding. I am pissed, though!
CLINICIAN: Yes, I’m getting that idea . . . (also grins)
CLIENT: I guess it is obvious, huh?! (calming down again)
clinician: Yeah, it’s hard to miss. But for some reason I am getting a
sense that this is more than anger.
CLIENT: (interrupts) You bet, it’s rage.
clinician: No, I mean something else. You know, another feeling, not
just lots of anger but something more, something else. . . . I’m not sure
what gives me the impression. It’s just I’ve seen you angry before, and
this feels different; like there is something else mixed into it. . . . Can you
help me out here?
CLIENT: Well, you could be right in some ways. I felt like crying on my

way over here. You know, like I was hopping mad, but at the same time
I had this urge to crawl in a corner and cry my eyes out. That’s weird,
isn’t it?
clinician: Maybe not. . . maybe it makes a lot of sense. A lot happened
here. Isn’t it possible that you have more than one reaction to it?
CLIENT: I suppose (hesitates), but what? Crying . . . like I’m depressed
or something?
CLINICIAN: Is that what comes to mind?
CLIENT: Not really; it doesn’t fit quite right. I just thought of that be¬
cause of the crying. Isn’t that when people cry, when they’re depressed?
CLINICIAN: Oh, my guess is people cry for all lands of feelings. . . .
CLIENT: Okay ... so what then?
CLINICIAN: Well, let’s try to figure it out. Take a deep breath and focus

inward, like we do so often. What do you notice?

CLIENT: (centers, breathes, and closes her eyes spontaneously, being used
to this type of work)
clinician: What’s under the anger (slow, gentle voice). . . what are the

tears trying to tell you. . . .

378 CHAPTER TWELVE

CLIENT: (keeps breathing and listening internally)

CLINICIAN: As it feels comfortable just tell me what comes up for you . . .
(cpiiet, long pause, waits patiently for client now)
CLIENT: (after some time) . . . There is a sense of tightness in my chest
that J’ve never felt before and yet it feels like a grip that I am familiar
with. Some old feeling coming back to me . . .
CLINICIAN: Some old feeling? (gentle, low voice)
CLIENT: Yes. Something sad, no, not sad, I’m not sure what it is . . . let
down, maybe. Like she should be a better person and my insides ache
because she isn’t. . . . That doesn’t make any sense, does it? (starts to
open her eyes)
clinician: Don’t worry about making sense for now. Just keep listening
to what your body is trying to tell you. . . .
client: Just that tight grip on my chest, my eyes watering (tears start
flowing now)-, oh, and my stomach is soft, gooey; how strange . . . not like
anxious, but also not mad anymore. Just soft, like I’m a little girl who
didn’t get what she earned. . . . (opens her eyes) What is this? Wow; this
is more intense than anger, and now that I’m in touch with it the anger is
gone. Like this is more important. . .
clinician: Like this is the real feeling and the anger was just a cover?
CLIENT: Exactly. And you know what, that’s what’s so familiar about it. I
think this has always been under the anger.
clinician: This sense of having been let down?
client: Yes! Disappointment! Not getting what I deserve. Not being
cared for, drawing the short straw. All of that. Oh my . . . (starts crying
softly )
clinician: An old hurt feeling . . .
CLIENT: Yes . . .
clinician: Does it remind you of anything?
client: Yes, yes it does (cries harder now). This is me as a little girl,
isn’t it? . . . (Session continues from here with an exploration of the origin
of this underlying affect that had been buried for years by the safer emo¬
tion of anger.)

This example demonstrates how Level Seven work often launches clients
into deeper understanding and profound exploration. It also serves to demon¬
strate why this type of work needs to occur after excellent rapport has been es¬
tablished between client and counselor. Often exploring underlying affects is
work that makes clients vulnerable as they begin to explore the deeper aspects
of their emotional life. The clinician needs to be able to help the client contain
emotion and needs to be perceptive to the client’s pain and limits. As in all here-
and-now work, the clinician needs to be prepared to deal with difficult affects
on the spot and needs to help the client throligh the experience and catharsis
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 379

of emotions that may heretofore not have been explored. Not all Level Seven
work will prove to be this profound or meaningful. Sometimes underlying af¬
fects are easily recognized and understood and do not affect the client on a deep
level. But, since the potential exists, the counselor is advised to be prepared for
the possibility. Also notable in this example is the fact that when working at this
level, clients often need little guidance regarding listening to their bodies. By
this time in treatment, they have learned to pay attention to their physiological
responses and are skilled about how to listen and attend to their bodies. Simple
encouragement by the counselor or therapist for the client to turn attention in¬
ward is usually sufficient.

Affect Continuum Exercise

The Affect Continuum Exercise is specifically tailored to work with clients who
are struggling at Level Five (that is, with the recognition of affective shades of
gray). Clinicians can often recognize clients who function at Level Five by their
all-or-none attitudes about feelings. These clients are unable to recognize that
any one affect can manifest at different levels of intensity. They conclude that
if they have a certain feeling, it is the same each time they experience it. Some
clients may shy away from particular affects altogether because of this attitude.
They are afraid that once they start the affect, they cannot stop it. This often
happens with depression. Clients do not allow themselves the experience of
sadness for fear of being completely overwhelmed by it. They fail to recognize
that sadness comes in different degrees, some of which are easily managed and
endured. This reaction is also common with regard to anger. Often, clients be¬
lieve that anger is inappropriate because when they think of their anger, they
associate it with an extreme behavioral response that they perceive as unac¬
ceptable. Then, instead of allowing any expression of even mild forms of anger,
they deny the entire affect. The inability to differentiate shades of gray can be
addressed through the Affect Continuum Exercise. It teaches clients to recog¬
nize subtle differences in their internal sensations and to apply new labels com¬
mensurate with these subtle differences, not just one emotion from another,
but also differing levels of intensity within the same affective category. This
type of intervention shares many of the features of here-and-now work. Thus,
all the cautions about counselor preparedness and client readiness apply.
The lists of affects provided in Table 12-1 will be helpful with the Affect
Continuum Exercise, although they are not ordered according to perceived in¬
tensity within each affect category. Such ordering is a highly personal arrange¬
ment. Clients differ greatly in what they may perceive as a continuum of affect.
For example, for some clients “furious” may represent more severe anger than
“enraged,” whereas others may switch their relative ranking. It is best to let each
client come up with a personal ranking, assisting merely by providing a list of
labels from which the client can choose. The exercise helps clients understand
380 CHAPTER TWELVE

that a particular affect need not be feared because of its potentially intense man¬
ifestation, as it can be experienced at lower levels of intensity that are manage¬
able and safe. As such, the exercise can at times result in work that actually rep¬
resents Level Eight, acceptance of affect. This is not usually the purpose, but
simply a useful by-product of the Affect Continuum Exercise.
Affect continuum work can vary widely from client to client and even from
affect to affect with the same client. It always involves helping clients develop
a hierarchy of labels for a given affect category by providing label options and
tying them to physiological arousal. Sometimes this work is done as the client
experiences the affect; sometimes the work is retrospective. If the work is done
with here-and-now experience, it resembles here-and-now work quite closely,
perhaps with the main difference being the more active participation of the
counselor in providing label options. If the work is retroactive, the client has to
recall feeling states rather than experiencing them in the present. Beyond that,
differences are minimal. Following is an example of an Affect Continuum Ex¬
ercise with a client who is experiencing affect right now. This example high¬
lights how affect continuum work can be used to help clients recognize that a
given affect does not always have to be overwhelming or disastrous. It can man¬
ifest in milder forms that are of little threat or consequence. Of course, this
work is not to be misused by the mental-health-care provider to minimize or
belittle a clients emotion; it is merely helpful in assisting the client to gain a
sense of control or acceptance of the affect.

CLIENT: I’m afraid I’m about to fall off the deep end . . . (weepy)
CLINICIAN: Help me understand . . .
CLIENT: Well, I think I’m depressed, just like my mother was when she
killed herself. . . (long pause)
clinician: Tell me more . . . (gentle but prodding voice)
CLIENT: I have been in a real funk ever since we figured out last week
that I’m depressed. You know that really scares me. My mother was ex¬
actly my age when she killed herself. What if I’m next? (shaky voice,
teary eyes)
clinician: Do you have thoughts of killing yourself?
CLIENT: Well, not really. But my mother was depressed when she did . . .
CLINICIAN: And so you are wondering if you might do the same?
CLIENT: Yes. It’s what depressed people do, isn’t it? . . . (pause)
clinician: It’s what depressed people do, you think? All depressed
people?
client: Well, all really depressed people . . .
clinician: Really depressed people . . . What about the other depressed
people?
client: (looks up puzzled)
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 381

clinician : Well, if there are really depressed people who kill themselves,
are there also not really depressed people who don’t?
CLIENT: Like some people who are less depressed?
CLINICIAN: (nods)
CLIENT: What do you mean?
CLINICIAN: Is it possible that there is more than one kind of depression?
Really depressed, and less depressed? And that one kind of depression is
so bad that killing oneself seems like the only solution and that another
kind of depression is less bleak?
CLIENT: Hmm . . . (clearly thinking)
CLINICIAN: Tell me about your depression, your sadness (beginning to
introduce a new possible label)
CLIENT: Well, it’s like we realized last week. ... I just can’t get much joy
out of life these days. And since yesterday it’s been particularly bad. I just
cried and cried last night after I watched this stupid TV show. No reason,
just felt really sad and down. Then I didn’t sleep well and then I dreamt
about my mother and that’s when I got scared that I might follow in her
footsteps.
CLINICIAN: So you’re feeling sad, down, nothing is fun, and you are hav¬
ing trouble sleeping. . . .
CLIENT: Yes.
CLINICIAN: Is this feeling ever better or worse?
CLIENT: Well, I guess yesterday before that TV show it was better,
but then seeing all these people in love just got me all down . . . (sobs
a little)
CLINICIAN: So in a way, in the last two days you’ve had at least two kinds
of depression; one that was less bad than the other?
CLIENT: Yeah, I suppose. . . .
CLINICIAN: Could we come up with separate labels for these so we can

differentiate them?
CLIENT: Like what do you mean?
CLINICIAN: Oh. Like the depression in the morning, before the TV
show, maybe that was blue or mellow or sad; and then the depression in
the evening after the TV show, maybe it was a little worse, like empty or
heavyhearted or in the dumps. . . .
CLIENT: Oh. . . .
CLINICIAN: Could you come up with some labels that would make sense
to you to describe the difference?
CLIENT: Well, in the morning I guess I felt kind of sad and then in the

evening I felt down in the dumps.

CLINICIAN: (accepting the client’s labels) So we have at least two levels of
depression—land of sad and down in the dumps. Have you felt other
382 CHAPTER TWELVE

levels of depression? Like what level might yon be at now? Worse than
down in the dumps or better?
CLIENT: Oh, when I first got here I was worse because I was so scared
that I was losing it. But right now I feel better. . . .
clinician: What might you call what you felt when you came in?
client: Oh, um, I don’t know . . . really, really bad? Is that okay?
clinician: Any label that makes sense to you and that seems to describe

what you feel is fine. . . .

CLIENT: Well, I don’t know, that seems too vague. . . . What are some
other words . . . well, maybe desperate. Yeah, that’s it, desperate.
clinician: Okay, so we have kind of sad, down in the dumps, desperate.
What might you call how you feel now? You said it was better than when
you came in. . . .
CLIENT: It’s worse than kind of sad but better than down in the dumps,
I suppose. Kind of dull in a way, like I can’t really think without being
made to think—you know, like you’re just making me do . . . (small smile)
clinician: (smiles too) So we are developing quite a list here. There
isn’t just one kind of depression, is there?
CLIENT: No, I guess not. I never really thought of it that way.
clinician: So, your mother, where do you think she was with her
depression?
CLIENT: Oh, more than desperate even! She must have been beyond
hope! . . . Oh . . . (looks up with a flash of insight) I just got what you are
doing with me. Not all depressed people kill themselves.
clinician: (nods) No, they don’t.
CLIENT: My mother was beyond hope, not just kind of sad or down in
the dumps. I’m usually down in the dumps or kind of sad. I’m not even
feeling desperate all that often. . . .
clinician: Right. Lots of levels of depression. You’ll probably find that
you have many, many other experiences of depression that we haven’t even
ranked yet. It may be worth it to keep track of how you feel each time you
feel depressed and then to try to figure out what that feeling means. . . .
client: (interrupts) Like order my feelings and then not get freaked
out if I’m just a little blue and rush in to see you if I ever get to feeling
beyond hope. ...
CLINICIAN: Exactly. . . . (Session continues from here.)
This example demonstrates how helping clients differentiate shades of gray
within the experience of a single affect not only clarifies their experience but
also gives them permission to experience the affect to begin with. It certainly
helps clients be more honest with themselves about what they may be feeling.
The example also demonstrates that differentiating levels of intensity can help
clients evaluate their reactions and physiological responses more realistically.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 383

Skill Development Recommendations

Recomriiendation 12-1 Choose an affect you commonly experience. De¬

velop a ranking of labels for the emotions within that affect category. Repeat
this exercise for any other affects you experience commonly, or that you
anticipate working with frequently. You may also want to try to do this with
a friend or family niember to get some idea about how people differ in their
choice of language or labels.

Focus on the Acceptance

and Understanding of Affect

As indicated previously, most higher-level affective work is actually quite cog¬

nitive in nature, relying mostly on cognitive strategies to help clients understand
why they feel what they feel. This section will highlight two strategies that can
be used if clients hesitate in their acceptance of an affect because they feel un¬
comfortable about it or do not trust that they can manage the affect in its more
severe forms. These strategies are focused on helping clients relax their bodies
so that they can gain a certain level of comfort and ease. Although these exer¬
cises, namely progressive muscle and inner-focus relaxation, have been covered
in the literature as strategies to deal with anxiety, they are actually applicable
for a wide range of emotions. Not only is it difficult for a body to be relaxed and
anxious at the same time, it is equally difficult to feel relaxed and angry, relaxed
and depressed, or relaxed and self-conscious. Relaxation will be introduced here
as a means of facilitating clients’ acceptance of their feelings when their initial
nonacceptance was based in the fear of not being able to manage the affect once
it emerges. Work regarding acceptance and understanding of affect that is not
based in the client s fear of the affect per se is cognitive in nature and is amply
demonstrated in the chapters on cognitive strategies. Strategies covered in those
chapters that have applicability to higher-level affect work (Levels Eight and
Nine) include pointing out patterns, clarification, here-and-now cognitive pro¬
cessing, confrontation, and interpretation.
All relaxation strategies are based on the premise that a body cannot be
physiologically aroused and relaxed at the same time. If a client can learn to re¬
lax the body willfully and purposefully, this skill can be used to counteract the
negative physiological reactions associated with other (negative) affects. If a cli¬
ent has learned to use breathing and muscle tension or focusing techniques to
384 CHAPTER TWELVE

reduce physiological arousal to a tolerable, perhaps even pleasant level, fear of

affect is reduced. The affect itself is not squelched, but the physiological arousal
is reduced to a tolerable level that reduces the impact of the affect on the body,
making it more acceptable and tolerable to the mind. Once fear of affect is re¬
duced, the client can become more accepting of the affect and can learn to cope
with it effectively, as well as being in a better psychological place to explore its
meaning and origins. Original applications of relaxation were fairly specific to
the reduction of anxiety. They focused on the elimination of general anxiety, the
reduction of anxiety about specific events, or on dealing with situation-specific
fears (for example, phobias about speaking in public), especially if combined
with guided imagery or systematic desensitization. The use of relaxation strate¬
gies as outlined in this chapter centers around helping clients gain a sense of
control over the level of physiological arousal experienced in their bodies to help
them tolerate and accept any affect that may be present or about to emerge.
A few cautions apply to the work with relaxation strategies. Relaxation exer¬
cises need to be used with caution with clients who have seizure disorders, phys¬
ical ailments involving pain (for example, arthritis or fibromyalgia), traumatic-
stress disorders, or psychotic disorders. The inexperienced clinician may want
to avoid altogether the use of these strategies with clients who fall into any of
these categories until experience has been gained. Experienced counselors
need to be prepared to deal with the possible side effects or consequences that
can occur with such clients. They also need to give proper cautions to the clients
affected and need to set up a warning system for the client should adverse ef¬
fects arise. For example, if clients with temporal-lobe epilepsy go through a re¬
laxation exercise, they need to be warned to open their eyes and to signal (in a
predetermined way) the clinician to change course, should they perceive col¬
ors, spots, or other signs suggesting the possible onset of a complex partial sei¬
zure. Similarly, fibromyalgia patients need thorough debriefing after the first
experience to assess whether any aspect of the relaxation exercises was uncom¬
fortable physically. It is probably best not to use progressive muscle relaxation
with such clients as the tensing of muscles maybe quite painful for them. Should
they not be able to make successful use of another relaxation strategy and a
muscle tension exercise has to be used, it is best to predetermine a signal that
tells the clinician that the client is in pain. Traumatic-stress clients may experi¬
ence flashbacks; both client and clinician need to be ready to deal with disso¬
ciative or similar affective crisis states. Psychotic clients who begin to have per¬
ceptual distortions during the exercise need to learn to signal the clinician when
this occurs so that the course of the exercise may be changed. In all of these
cases of caution, once the client has signaled the clinician that discomfort or
threat is present, the counselor calmly redirects the exercise to simple breathing
and then slowly and calmly brings the client back to the present. The exercise
is not abandoned abruptly, rather, a gradual and calm transition is made to al¬
low the client to emerge from the relaxed^to the normal wakeful state of being.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 385

Most importantly, the clinician must not panic at the clients signal but behave
calmly and with an air of reassurance and safety.
For all relaxation exercises, clients need to be carefully prepared. The cau¬
tions outlined above are only one aspect of the information that is shared with
the client. Complete and proper preparation involves sharing all of the follow¬
ing information with the client the first time the strategy is used:

• rationale for and purpose of the use of the strategy

• details about what the exercise will involve and how long it will take
• directions about positioning and comfort (lying versus sitting; use of a
blanket in case of feeling cold; taking shoes off; closing eyes; and so on)
• details about the fact that the clinician plans to prepare a tape of the ex¬
ercise, so the client can relax during the exercise without having to focus
on remembering what was done for future use
• details about the breathing exercises that will precede the relaxation
strategies (see Breathing Exercises above)
• reminders that the client cap open the eyes or discontinue following the
instructions at any point in time or if pain, discomfort, or fear should arise
• cautions about the use of the strategy in the presence of particular pre¬
senting problems such as seizures, traumatic stress, pain disorders, or
psychosis and exploration of these symptoms in the client
seizure disorders: tell client to open eyes if perceptual phenomena,
such as colors, spots, or lights, occur
traumatic stress: tell client to open eyes or use agreed-upon signal if
dissociative state appears imminent or if fear occurs
psychosis: tell client to open eyes and use agreed-upon signal if per¬
ceptual disturbance threatens or begins
pain disorder: tell client to use agreed-upon signal should pain occur
• warnings about possible effects that may occur, along with actions to be
taken by client or clinician
experience of heaviness: normal experience requiring no action on
the part of the client unless it is perceived as uncomfortable
experience of lightness or floating: normal experience requiring no
action on the part of the client unless it is perceived as uncomfort¬
able or frightening
pain in a muscle group of focus: develop a signal for the client to cau¬
tion the clinician to change instructions
perceptual phenomena (for example, seeing colors): normal experi¬
ence for most clients requiring no action on the part of the client
unless it is perceived as uncomfortable or frightening (red flags
requiring immediate action with seizure or psychotic patients)
falling asleep: normal experience monitored by the clinician and
requiring no action on the part of the client
 i

386 CHAPTER TWELVE

• instructions and agreement about a signal the client will be able to use to
communicate with the clinician in a case of need (for example, raising the
index finger of the right hand, shaking the head side to side)

Once the client has understood this information, the exercise can begin.
During the initial phases of the exercise, some of this information can be re¬
peated in a calm and comforting tone that makes it part of the induction phase
of the exercise. For example, the client can be reminded of the options for sig¬
naling the clinician-opening the eye or making a special, predetermined signal
that cautions the clinician about client discomfort, and of the value of deep and
rhythmic breathing. Once the client is in a comfortable position, exercise in¬
structions are delivered in a low, calm, soothing voice that is relatively monotone
and perhaps even perceived as boring, due to the lack of inflection. Relaxation
exercises always begin with deep breathing (as outlined above) and proceed
from there to either progressive muscle work or inner-focus work. Instructions
are highly repetitive and monotone; they are easily followed and highly descrip¬
tive. Work usually proceeds by relaxing peripheral parts of the body first and
slowly moving toward the center of the body. Throughout the work, the coun¬
selor gives reminders to the client to retain the relaxation in parts of the body
that have already been worked on. Following are instructions for muscle tension
and inner-focus relaxation strategies. Many other variations of relaxation work
exist, and each mental-health-care provider will ultimately develop a preferred
set or two of instructions. The examples provided here are merely to give the
clinician some ideas about how relaxation exercises can proceed. Modifications
are not only possible, but recommended, based upon clinician preferences and
client needs. As is true for all of the structured exercises covered in this chap¬
ter, relaxation exercises begin with an introduction, proceed to actual instruc¬
tions, and end with a thorough debriefing.

Progressive-Muscle-Relaxation Exercise
Progressive muscle relaxation is based on inducing relaxation by contrast. Each
muscle group in the body is first tensed, then relaxed, and the client s attention
is then drawn to the difference in the tense-versus-relaxed state of each muscle.
It is the attention to the difference in the experience of a tense-versus-relaxed
muscle that is the mediator of overall relaxation for the client. Progressive
muscle relaxation is easier to deal with for most clients in their early attempts
at relaxation, though it appears that inner-focus work can lead to deeper levels
of relaxation. Thus, it may be best to start clients with muscle tension work and
then to graduate to inner-focus work once the client has achieved some success
with muscle tension work. For some clients, most obviously pain sufferers,
muscle tension work is less than optimal. For them, the tensing of muscles may
be so painful as to counteract the relaxing effect. Therapists will have to use
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 387

their clinical judgment about when not to use this type of relaxation with cli¬
ents. Muscle tension relaxation exercises can be completed sitting up or lying
down based on the client’s preference. The instructions that follow are based
on a client who is lying down. Only minor modifications are necessary for work
with clients who prefer to sit. Some clinicians engage in the muscle tension and
relaxation along with the client to get the timing right and to knctw firsthand
what the client is experiencing. This is a personal preference of each therapist
or counselor. Regardless of whether a clinician does the exercise with the cli¬
ent, it is probably best to have personally done the exercise at least three or four
times before using it with a client. This will give the counselor a better appre¬
ciation of what it is the client is feeling as various muscles are tensed and re¬
laxed. It may also prevent the therapist from giving a tensing instruction that is
painful. One final note: The first time the exercise is used, the whole session
needs to be dedicated to it to give plenty of debriefing time. Thus, if the idea
for the use of relaxation comes up toward the end of a session, the client can be
prepared for it (some of the introduction can be given), but will not begin the
actual exercise until the next session, when a brief review of the introduction
will precede the exercise. Debriefing time after the first use of the exercise is
essential and this is one caution that is best always followed.

Introduction to Progressive-Muscle-Relaxation Exercise

“One thing that you might find helpful in dealing with [insert client s dif¬
ficult affect here] is something called progressive muscle relaxation. The
exercise helps you relax and calm down when you are feeling [client’s af¬
fect] and may help you not [fear that affect] in the future. It’s also a great
exercise to do anytime you feel anxious or upset, or even when you’re
having trouble sleeping. You can use it for lots of things and in lots of
places. Does this sound interesting?”

Clinician gives client a chance to respond; this is important as many clients

have already heard of relaxation exercises and may have a reaction (positive or
negative) that is best processed before proceeding. Then the introduction con¬
tinues. Based on client interactions, some portions may be addressed in a dif¬
ferent order than presented here. The main point is to cover all aspects; order
is irrelevant.

“Great. Well then, let me tell you a little bit about what the exercise in¬
volves. The ultimate goal is to get you to be able to relax and feel calm
and collected. The easiest way that seems to happen for a lot of people is
to pay attention to how their body feels when it’s tense versus how it feels
when it’s relaxed. So what I’ll do is I’ll talk you through lots of different
body parts, asking you first to tense certain muscles and then to relax
them. All along I’ll give you some things to pay attention to. The exercise
388 CHAPTER TWELVE

is pretty easy—you just follow my directions. And don t worry about re¬
membering what I’m doing because if this turns out to be something you
enjoy, I will make a tape for you that you can take home so that you can
practice at home if and whenever you feel like it. So far, so good?”

Clinician gives client another chance to respond; then continues with

introduction.

“Also, if at any point I’m giving you a direction and you try it and it hurts
or doesn’t feel comfortable, you definitely don’t have to do it. If I ever get
off on my timing and I’m asking you to tense longer than feels good to
you, feel free to let go of the tension in the muscle. Do try to give it a fair
chance first, though. If you need to, you can signal me that you are un¬
comfortable. Just [raise your right index finger]. Alright?”

Clinician gives client another chance to respond, then continues with

introduction.

“Now, before we get started I want to double check a few things. I think I
already know the answers to these questions but I always like to double
check. First, do you have any physical problems that I should be aware of
that may be affected by this exercise? For example arthritis, fibromyalgia,
or any other kind of pain problems?”

Clinician gives the client a chance to respond, then continues checking on all
relevant contraindications in the same manner, that is, similar questions are
then phrased for seizure disorder, dissociative episodes, and if necessary (it
usually should not be), psychotic sijmptoms.

“Okay, now that I have ruled out that you have any symptoms that may
get worse during this exercise, let me tell you about a few things that
you may experience. Sometimes people get a floating or a heavy feeling.
That’s perfectly normal. In fact, it is usually a sign of very deep relaxation.
Should this upset you, though, just use the same signal we talked about
earlier. So, if you want me to help you out of the feeling because it’s un¬
comfortable, just [raise your right index finger]. Does that make sense?”

Clinician gives the client a chance to respond, then continues by running

through all the cautions noted above (for example, pain, colors, perceptual dis¬
turbances, falling asleep). If the client wishes, a different signal can be arranged,
for different eventualities. The clinician needs to walk a fine line here between
helping the client knoiv what to expect and scaring the client about too many
potential dangers of the exercise. Thus, arranging multiple symptoms may be
reserved for the deb riefing with those clients who did indeed experience some
difficulties with the exercise.
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 389

“Alright. Now that we have that covered, let me remind you that you
don’t need to worry about remembering what I’m doing because I can
tape this for you next time we use the exercise. Also, this will take about
twenty-five to thirty minutes. I’ll start the exercise with the breathing ex¬
ercises we have been doing [describe the breathing exercises as above if
they have never been used]. You can sit up or lie down, whichever feels
more comfortable. The exercise usually works best if you have your shoes
off and your eyes closed. Some of the directions I’ll give you will sound
funny and you may feel a little self-conscious. Just remember, no one is
watching, so go for it anyway. I have a blanket here that you are welcome
to use if you might get a little chilly lying still so long. You can also use
the pillow, if you’d like. Any questions?”

Clinician provides one final chance for comments and questions, then, once the
client is settled into a comfortable position, begins with the actual exercise
instructions.

Instructions for Progressive Muscle Relaxation

“Now that you are settled into a comfortable position, go ahead and close
your eyes. This will draw your attention to the inside of your body. Con¬
sciously focus your mind inside your body now and follow my instruc¬
tions. Start by taking a deep breath in through your nose and then out
through your mouth.”

Here the clinician takes in a deep audible breath through the nose and then
blows the breath out through the mouth. This may be done a couple of times.

“And breathe in”

Clinician inhales audibly.

“ . . . and out through your nose”

Clinician exhales audibly through the nose.

“And in . . . and out. . . and in . . . and out.”

Clinician establishes a comfortable audible breathing rhythm. This should be

done without speaking for about twenty seconds, or whatever period of time is
comfortable for the client.

“Now as you keep breathing deeply and comfortably, direct your atten¬
tion to your feet. . . . On your next breath in, curl your toes downward.
Notice the tension this position creates in your feet. . . . Notice the tight¬
ness_Feel the tension, . . . and then let go-Let your toes return to
their normal position, . . . and notice the difference. . . . Notice how re¬
laxation feels different from tension. . .. Now, curl your toes one more
390 CHAPTER TWELVE

time. . . . Study the feeling of tension, ... of tightness, . . . and notice the
difference in the feeling in your toes as they are tight. . . and tense. . . .
Now let go . . . and enjoy the difference. . . . Enjoy the relief. . . of letting
go of tension, ... of relaxation . . . flooding into your toes ... as you let
them relax into their normal position. . . . Study the difference between
tension . . . and relaxation. ... All along,. . . keep breathing in . . . and
out... at a comfortable rate.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

“Now flex your feet, toes toward knees. . . . Tight, . . . and tighter. . . .
Study the tension this creates in the back of your calves, ... in the bot¬
toms of your feet. . . . Study the tightness, . . . the tension, ... as you flex
your feet. . . toward your knees. . . . When you are ready, . . . relax your
feet to their usual position . . . and notice the difference. . . . Notice the
relaxation . . . pouring through your feet. . . and calves ... as you relax
your feet. . . . Study the difference between relaxation . . . and tension. . . .
Notice the warmth . . . and comfort... of the relaxation . . . pouring
through your feet. ... So different. . . from the tightness you felt
before. . . . Flex your feet one more time. . . . Notice the tightness, . . .
the tension. . . . Now let go . . . and explore the difference. . . . Enjoy the
warmth . . . and comfort... of relaxation. Recognize the good . . . feeling
of relaxation, . . . the ease . . . and peace in your feet. . . when they
relax ... in their natural position. ... All along, . . . keep breathing in . . .
and out... at a comfortable rate.”

Clinician inhales and exhales audibly.

“And in . . . and out.”

Clinician inhales and exhales audibly.

[The clinician now repeats essentially the same instructions, as indicated

thus far, for any or all of the parts of the body listed below. These in¬
structions need minimally to include:

• the appropriate repetition of each movement

• proper pacing of tension (not too long)
• adequate breaks between tensing of muscle groups
• comparison statements of relaxation versus tension
• reminders to keep other parts of the body relaxed while tensing the
targeted muscle groups, and
• refocusing on the breath between body parts
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 391

The clinician will work from the periphery of the body to the core; for
each body part the following tension movement is recommended:

• thighs: hold legs out straight (either both at same time or one at a
time); if too difficult, plant feet firmly on ground and push down as
hard as possible
• buttocks: scrunch buttocks toward each other
• hands: make a tight fist, thumb on the outside, keeping arm relaxed
• wrists and lower arms: make a fist and curl hands toward the inside
of the elbow joint (do not flex elbow joint)
• arms and elbows: with hands in a fist pointing toward the shoulder,
flex lower arm up (curl)
• shoulders: shrug shoulders up toward the ears
• neck: first lean head toward right shoulder; on repetition, lean head
toward left shoulder; or drop head to chest
• forehead: wrinkle up forehead only (not eyes), easiest done by rais¬
ing eyebrows toward scalp
• eyes: clench eyes shut tightly; this might wrinkle up the nose as well
• mouth: purse lips tightly as if about to peck a kiss
• jaw: open mouth wide; may also stick tongue out as far as possible
• entire face: squeeze eyes shut tightly, purse lips, wrinkle up fore¬
head (pucker up whole face)
• chest: after a deep inhalation, hold breath and push shoulders back
• abdomen: stick stomach out as far as possible; or tighten abdominal
muscles and sphincter

Then tire clinician once again refocuses the client on the breath and pro¬
ceeds with the following instructions.]

Clinician inhales and exhales audibly.

“Your whole body is relaxed now. . . . Every part of you is calm . . . and
quiet, . . . warm . . . and tingly . . . with relaxation. . . . You are relaxed . .
from your toes to your hips, . . . from your fingertips to your shoul¬
ders, . . . from your neck to your forehead, . . . from your eyes to your
chin, . . . from the outside in. . . . Enjoy this relaxation . . . and the
warmth . . . and comfort it brings. . . . Enjoy the difference of relaxa¬
tion . . . versus tension. . . . Revel in your calmness. . . . Treasure . . . the
warmth . . . and comfort. ... As ypu breathe in . . . enjoy your restful¬
ness, . . . and as you breathe out. . . savor your calmness.”

Clinician inhales and exhales audibly.

“Enjoy your peacefulness ... as you breathe in deeply. . . . Relish your

stillness ... as you breathe out fully. . . . Calm . . . restful. . . tranquil. . . .
Fully and completely relaxed.”
39:2 CHAFTER rvvvlW

After a comfoctabie amount if that Ar tiwWm «sfcs the client h» eml the fa-
mw <*s fivkxrs

Now that whi have vvxTcor.iod calmness and pe.xx'ti '..ness. o\jvr.
cased the warmth „.. and comfort of wtoBw^ - - - sh'vvh bring back
wnir awareness Kick to this non, -.. bringing wnir tnatfuMH) Mbd
relaxation_with you.... Knowing that on CM go back ... to this »*
laved state anv true wvu wan: to
* »
Slow v :vc" to \vi;s vein attcu
* ** '

tion... awav from whu Ixxtv and whu breath . hark to the miter
world.... Do that by beginning to notice any sounds that whi max
hear.... bv moving whit bodv in any way that's eomtortable. As war
do this. 1 will sfowh begjm to count hack from to e tv' om'
W ith each number l say. whi will Kwme moiv ami morx' alert
When 1 get to one.... whi will be fully alert.... Then take whatewr
time whi need... and when whi re ready ... open \ oui ej os

Clinician shady counts thick from fret to one. incrtnang vohtme of rotor ns
numbers thermae* and adjusting the time tequiml to the needs <f the cheat

"Five. .. becoming more alert and aware of the outside world

Four. — aware of the sounds might mention specific audible ' . avis
here .... rousing the body. ... Three.... becoming more and more
alert and aware.... Two.... coming back tv' the here-and-now. .
One.... fully alert and aware!

Clinician now' aifotrs the client to /xnv her or his ou'n retorn by rrinefning
quiet until the client opens the eyes and makes eye contact with the clinician.
Once the client isjfuUu eU'rt and ;a;s ivganio/ am fact uirn r:;c clinician. de¬
briefing ct:n fvgin.

Debriefing on Progressive Muscle Relaxation

In tire debner.r.g tire ^ Ihucian attempts to had out how the client responded tv'
the exercise. tltat is. it the exercise has met its purpose Often, the simple ques
tiv'n "How .ire whi teeling- is a perfect opening tor exploring the effect ot the
exercise Tiutiitg is crucial. It is K'st to begin questioning genth and cahnb oiuv
the client has opened the eyes turd has reestablished eye contact with the cli¬
nician. Some clients volunteer information spontaneously that is preferable.
Once the coimselor has a handle on how the client feels and whether the exer¬
cise met its purpose, the therapist explores what, it anything, was particulars
helpful to the client and what, if anything, mav have been less than conducive
a' the client's relaxation or comfort It is important to elicit detail from the cli¬
ent. perhaps asking tor specific feedback about a few of the tension movements
to make sure the client is responding in a detailed manner.
It a client signaled discomfort during the exercises, the clinician must re¬
member and follow up on the incident to investigate what caused the diseom-
 WORKING WITH AFFECT AND EMOTION FOCUS ON FEELINGS 393

fort, to consider its consequences, arid to plan future changes in the exercise to
prevent a similar occurrence. It is often helpful to phrase the question in a
manner that reminds the client of what was going on at the time of the dis¬
comfort. The question may be phrased as follows: “While we were working on
your hands by making a fist you indicated distress by [raising your right in¬
dex finger! 'A hat was going on for you right then?" The client is asked if any
modifications might be helpful and if anything in the exercise appeared strange
or unusual. The client is also specifically asked about self-consciousness about
tensing certain muscle groups, knowing of the clinician’s presence. It is often
helpful to ask about the specific cautions dor example, pain, colors, heaviness,
floating; to see if an;, of these issues arose for the client and how this was dealt
with b;. the client It is always good practice to be as specific as possible in ques¬
tioning after the first use of the exercise and riot to rely on brief answers about
the client s experience. It is crucial to be open to negative feedback from clients
lest they not derive necessary benefits from future modifications. For example,
;f a client indicates that the clinicians voice was too loud or too soft, the clini¬
cian must not be offended but be grateful to have this information so that the
voice can be adjuster! during the next attempt at the exercise. The question "Is
there anything I might have done that would have made this experience even J
better for you ?" usually works well to elicit such feedback.
(>nce sufficient feedback has been collected, the clinician can make a plan
for future use of the exercise. The clinician may decide to continue to practice
the exercise with the client in session for a few more weeks to have a way of
monitoring progress in its use If the client was very successful in the use of the
exercise, the clinician may decide only to use counseling time once or twice
more and then to encourage the client to use the exercise on private time. If
the client is encouraged to use the exercise on her or bis own, a tape can be
made. If only minor modifications appeared necessary, a tape can be made dur¬
ing
£? the next use of the exercise in session for the clients later home use. if rna-
jor modifications are needed the exercise may need to be repeated in session
a few more times before taping is in order. All cautions about taping and the
recommended use of tapes that /.ere spelled out for the bodywork exercises
apply here as well.

Focwfinff-Belaxation Exercize
As indicated above, clients are usually not introduced to inner-focus work un¬
til thee have bad some success with muscle work unless there was a reason not
to use progressive muscle relaxation. 'Hie introduction and debriefing for this
relaxation exercise are essentially identical to those for progressive muscle
work The main difference rests on the description of what svili be done during
the exercise that is paying attention to various muscle groups and parts of the
bodv without tensing and relaxing of muscles;. Since the client is completely
394 CHAPTER TWELVE

at rest throughout this exercise, it may be helpful to have a blanket available for
clients who have a tendency to feel cold, as coldness tends to distract the cli¬
ent’s focus away from relaxation. As was true for progressive muscle work, the
client can work sitting up or lying down. The main issue is for the client to find
a comfortable position that can be maintained easily for the duration of the ex¬
ercise. Some trial and error may be necessary. Given the similarity of the in¬
troduction and debriefing, following are only the actual instructions for the Fo¬
cusing-Relaxation Exercise. The reader can use the specifics provided in the
instructions to modify the relevant portions of the introduction about what the
exercise involves. All debriefing comments (except those regarding muscle
tensing) apply to this exercise as stated above.

Focusing-Relaxation Instructions
“Now that you are settled into a comfortable position, go ahead and close
your eyes. This will draw your attention to the inside of your body. Con¬
sciously focus your mind inside your body now and follow my instruc¬
tions. Start by taking a deep breath in through your nose and then out
through your mouth.”

Here the clinician takes in a deep audible breath through the nose and then
blows the breath out through the mouth. This may be done a couple of times.

“And breathe in”

Clinician inhales audibly.

“. . . and out through your nose.”

Clinician exhales audibly through the nose.

“And in . . . and out. . . and in . . . and out.”

Clinician establishes a comfortable, audible breathing rhythm. This should be

done without speaking for about twenty seconds, or whatever period of time is
comfortable for the client.

“Now as you keep breathing . . . deeply . . . and comfortably, . . . direct

your attention to your feet. . . . Open yourself... to the experience of
warmth . . . and relaxation ... in your feet. . . . Focus your mind on the
comfort... in your feet,. . . recognizing it... as relaxation . . . and notic¬
ing it... as calmness. . . . Notice the calm . . . and peace ... in your'
feet... as they rest comfortably ... on the couch. . . . Enjoy this pro¬
found tranquillity ... in your feet... as they relax . . . more and more . . .
completely. ... All along, . . . keep breathing in . . . and out... at a com¬
fortable rate, . . . breathing relaxation and calmness . . . deep into your
body . . . with each breath in . . . and inviting deeper and deeper tranquil¬
lity . . . and peacefulness . . . with each breath out.”
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 395

Clinician inhales and exhales audibly.

“Breathe in . . . fully relaxed . . . and calm . . . and out. . . peaceful. . .

and quiet.”

Clinician inhales and exhales audibly.

“Keep breathing . . . deeply . . . and comfortably, . . . keep enjoying the

relaxation . . . and comfort... in your feet. . . and direct your attention
to your calves, . . . noticing . . . that the good feeling ... of calmness ... is
spreading up . . . from your feet. . . into your legs now, . . . into your
calves. . . . Calmness . . . and comfort, . . . warmth . . . and tingling ... in
your lower legs ... as a profound sense of relaxation . . . and calmness . . .
travels through . . . your lower legs. . . . Supporting the comfort. . . and
tranquillity ... in your calves ... is the peacefulness . . . you breathe
in . . . with each inhalation, . . . and the restfulness . . . and release . . .
that comes . . . with each exhalation.

Clinician inhales and exhales audibly.

“Breathe in . . . fully relaxed . . . and calm . . . and out. . . peaceful.'. .

and quiet.”

Clinician inhales and exhales audibly.

“Keep breathing deeply and gently, allowing the relaxation to spread fur¬
ther now, up your legs through your knees into your thighs.” [The clini¬
cian now repeats essentially the same instructions (with the appropriate
pacing, breaks, suggestions of calm and relaxation, and refocusing on the
breath), as indicated thus far, for any or all of the following body parts,
working from the periphery of the body to the core:

• spreading relaxation from thighs into hips and pelvis

• spreading relaxation from fingertips throughout the fingers
• spreading relaxation from fingers into the entire hand
• spreading relaxation from the hand into the wrist and lower arm
• spreading relaxation from the lower arm through the elbow to the
upper arm into the shoulder
• spreading relaxation from the shoulder to the neck and spine
• spreading relaxation from the neck up the skull across the entire
scalp
. spreading relaxation from the top of the head to the forehead and
eyes
. spreading relaxation from the eyes across the rest of the face
. spreading relaxation from the face down to the chin and throat and
on to the chest
• spreading relaxation from the chest to the abdomen
396 CHAPTER TWELVE

Then the clinician once again refocuses the client on the breath and pro¬
ceeds with the following instructions.]

Clinician inhales and exhales audibly.

“Your whole body is relaxed now. . . . Every part of you is calm . . . and
quiet, . . . warm . . . and tingly . . . with relaxation. . . . You are relaxed . . .
from your toes to your hips, . . . from your fingertips to your
shoulders,. . . from your neck to your forehead, . . . from your eyes to
your chin,. . . from the outside in. . . . Enjoy your relaxation . . . and the
warmth . . . and comfort it brings. . . . Enjoy the peacefulness ... of re¬
laxation. . . . Revel in your calmness. . . . Treasure . . . the warmth . . . and
comfort. ... As you breathe in . . . enjoy your restfulness,. . . and as you
breathe out. . . savor your calmness.”

Clinician inhales and exhales audibly.

“Enjoy your peacefulness ... as you breathe in deeply. . . . Relish your

stillness ... as you breathe out fully. . . . Calm . . . restful. . . tranquil. . . .
Fully and completely relaxed.”

After a comfortable amount of time, the clinician asks the client to end the ex¬
ercise as follows:

“Now that you have welcomed calmness . . . and peacefulness, . . . experi¬

enced the warmth . . . and comfort of relaxation, . . . slowly bring your
awareness back to this room, . . . bringing your tranquillity . . . and relax¬
ation . . . with you. . . . Knowing that you can go back ... to this relaxed
state . .. any time you want to. . . . Slowly begin to focus your attention . . .
away from your body and your breath . . . back to the outer world. . . .
Do that by beginning to notice any sounds that you may hear, ... by mov¬
ing your body in any way that’s comfortable. ... As you do this, ... I will
slowly begin to count back . . . from five to one. . . . With each number I
say,. . . you will become more and more alert. . . . When I get to one, . . .
you will be fully alert. . . . Then take whatever time you need . . . and
when you’re ready . . . open your eyes.”

Clinician sloivly counts back from five to one, increasing volume of voice as
numbers decrease, and adjusting the time required to the needs of the client.

“Five,. . . becoming more alert and aware of the outside world. . . .

Four, . . . aware of the sounds [might mention specific audible sounds
here], . . . rousing the body. . . . Three, . . . becoming more and more
alert and aware. . . . Two, . . . coming back to the here-and-now. . . .
One,. .. fully alert and aware!
 WORKING WITH AFFECT AND EMOTION: FOCUS ON FEELINGS 397

Skill Development Recommendations

Recommendation 12-2 Practice one or both of the relaxation exercises

with a friend or family member. You may want to start by reading from the
script, and then try it from memory. Pick a friend, who is willing to give hon¬
est feedback about your technique. Practice with this person until they report
enjoying the exercise and deriving benefit from it. Then try it one more time
with another friend or family member before using the exercise with a client.

Recommendation 12-3 Alake a tape of one or both of the relaxation exer¬

cises for you r own use. Practice the exercise a few times until you get an ap¬
preciation of what it feels like for the client. If you have a f riend or peer who
can guide you through the exercise, that may be an acceptable substitute to
making a tape. The main idea is for you to experience the exercise so that you
can identify with what your future clients will go through.

Clinician now allows the client to pace her or his own return by remaining
quiet until the client opens the eyes and makes eye contact with the clinician.
Once the client is fidly alert and has regained contact with the clinician, de¬
briefing can begin.

Final Thoughts

The complexity of therapy and counseling has no doubt by now become ap¬
parent. There is much to know and do to help clients grow and change. The
techniques introduced in this book serve as a solid foundation for clinical work.
Combining them flexibly and logically according to the individual needs of each
client will mark the successful clinician. Any technique presented in this book
can be useful or hurtful depending on how it is used and the context in which
it is used. Learning how to apply knowledge in a skillful and caring way is the
most important next step in the process toward becoming a counselor or ther¬
apist. To take the next step, it is important for the developing clinician to begin
to practice, first with peers, then with real clients, and to read, read, read.
There are many wonderful counseling and therapy books. Many of them have
been referred to in these pages and are listed in the reference section that
follows. For those readers who would like to continue to read in the same style
as was presented in this book, two other books by this same author may be par¬
ticularly helpful. These are as follows:
398 CHAPTER TWELVE

Brems, C. (1999). Psychotherapy: Processes and techniques. Boston:

Allyn & Bacon.
Brems, C. (2000). Dealing with challenges in psychotherapy and counsel¬
ing. Pacific Grove, Calif.: Brooks/Cole.

For those readers who want to expand their work to include child clients,
the following book may be useful:

Brems, C. (1993). A comprehensive guide to child psychotherapy. Bos¬

ton: Allyn & Bacon.

Practice of the Skill Development Recommendations made throughout

this book will be an excellent start toward the goal of refining therapeutic skills.
In-class exercises (often done in groups) will augment these experiences and
will help with the necessary confidence building. Once mastered at these lev¬
els, the skills can then be used with clients.
I wish you good luck with these techniques and a happy career in mental
health.
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; • - *

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■
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‘I

'
Author Index

Ackerman, P., 182 Berman, P. S., 253

Adair, M., 84 Bernstein, I., 35
Adler, A., 250 Berren, M. R., 107
Alarcon, R. D., 65 Beutler, L. E., 107
Alexander, C. M., 56, 57, 68 Bhawuk, D. S., 65
Allen, D. B., 65 Birch, K., 182
American Counseling Association, 42 Bohart, A., 250
American Psychiatric Association, 65, 255 Borysenko, J., 84, 85
American Psychological Association, 42, Borysenko, M., 85
56 Boulet, D. B„ 192
Anderson, B. S., 42 Brems, C., xix, 11, 21, 28, 29, 33, 44, 66,
Armelius, B. A., 33 69, 70, 72, 99, 131, 151, 184, 188,
Armour-Thomas, E., 64 200, 203, 226, 248, 252, 255, 265,
Assaglioli, R., 250 311,312,398
Atkinson, D. R., 61 Brislin, R., 68
Atwood, G., 266 Brown, L. S., 320
Axelson, J. A., 57 Brown, R. W, 21, 26, 27, 250
Brown, W J., 68
Balch, J. F., 90 Buckley, T., 182
Balch, P. A., 90 Burns, G. W, 95, 96
Bandler, R., 250
Bandura, A., 204 Callanan, P, 34, 41, 42, 43
Barnouw, V., 64 Canter, M. B., 42
Barrett-Lennard, G., 28, 184, 188 Cargile, A. C., 68
Basch, M. E, 26, 28, 253 Carkhuff, R. R., 199
Bateson, C. D., 182 Carter, R. T., 62
Bayne, R., 75, 92 Casas, J. M„ 56, 64, 68
Beck, J. S„ 249 Castillo, R. J., 65
Beliak, A. S., 249, 317 Choca, J. P, 26
Beliak, L., 317 Chrzanowski, G., 27
Bemark, F., 309, 310, 311 Clarson, S., 70
Bennet, M. J., 68 Coleman, H. L., 57
Bennett, B. E., 42 Conaway, L., 65
Ben-Porath, Y. S., 27 Corey, G„ 21, 34, 41, 42, 43

411
412 AUTHOR INDEX

Corey, M. S., 34, 41, 42, 43 Gibbs, J. T., 62

Cormier, L. S., 17, 21, 25, 26, 27, 28, 248, Gil, E„ 318
278, 280 Gill, M„ 266
Cormier, W. H„ 17, 21, 25, 26, 27, 28, Glenn, J., 35
248,278, 280 Goldstein, J., 78
Corsini, R. J., 250, 310 Gopaul-McNicol, S. A., 64
Cottone, R. R., 41, 42, 46, 47 Greenberg, L. S., 250
Crayhon, R., 90 Grinder, J., 250
Cross, W E., 61 Gutldn, T., 57
Cuellar, I., 63
Haas, E. M., 90
D’Andrea, M., 57 Hackney, H., 25
Dana, R. H„ 62, 63, 65, 68 Hammond, D. C., 200
Daniels, J., 57 Hanh, T. N„ 82
Das, L. S„ 72, 76, 78, 81 Harris, I. C., 63
Davis, M. H., 182, 183, 184 Harvey, D. R., 18
Day, J., 13, 15 Hayano, D., 62
Dillard, J. M„ 62 Heck, R., 57
Dimberg, U., 95 Helms, J. E., 62, 63
Dolan, Y. M„ 318, 319 Hepworth, D. H., 200
Donner, S., 204 Herlihy, B„ 21, 42
Dorfman, R. A., 27 Hernandez, A., 57
Driver, R., 95 Herson, M., 249, 317
Dryden, W, 250 Hirai, T., 76
Duncan, B. D., 182 Hoffman, C., 27
Holmquist, R., 33
Eells, T. D., 253 Hoy, D„ 247
Egan, G„ 24, 25, 121, 188, 193 Huang, L. N., 62
Ellis, A., 250
Epstein, M., 291 Iijima Hall, C. C., 54, 56, 65
Epstein, N., 182 Ivey, A. E„ 57, 184, 185, 256, 279
Ivey, M. B„ 184, 185, 256, 279
Fairweather, D. R., 192
Fields, R., 82 Jackson, B., 61
Fishman, H. C., 249 Jackson, T. T., 253
Fogelsanger, A., 84 Jasso, R., 63
Foster, S. L., 65 Jevne, R. F., 73
Foulks, E. E , 65 Johns, H„ 73, 74
Fox, M. W, 87 Johnson, M. E., 11, 57, 64, 71, 200,
Frankl, V. E„ 250 204
Fretz, B. R., 250 Johnson, R. A., 75
Freud, S., 33, 75 Jones, S. E., 42
Fromme, D. K., 200 Jones, W T., 62
Jung, C. G„ 75, 249
Gallucchi, P., 11
Garfield, P., 75 Kabat-Zinn, J., 78
Garrett, L,, 94 Karoly, P., 253
Gelfand, M. J., 65 Kazdin, A. E., 249, 317
Gelso, C. J., 250 Keinan, G., 27
Gendlin, E. T„ 249 Kim, M. S„ 67
 AUTHOR INDEX 413

Klinger, K. W, 92 National Association of Social Workers,

Knapp, M. L., 104 42
Knobel, M., 26, 27 Natterson, J., 266
Kohatsu, E. L., 63 Nelson, J., 253
Kohut, H„ 27, 28, 30, 96, 183, 184, 191, Newman, J. R., 92
192, 196, 201, 202, 203, 205, 249, Nichols, M. P., 279
280 Null, G„ 86, 90
Kolevzon, M. S., 27
Kornfield, J., 78 Olson, K. R„ 253
Kottler, J. A., 21, 26, 27, 250 Olson-Webber, L., 317
Krebs, D., 182
Parham, T. A., 63
L’Abate, L., 250 Patterson, L. E., 185, 188, 191
LaFramboise, T. D., 57, 8 Pearce, S. R., 249
Land, H„ 25, 27 Pennebaker, J. W, 75
Lane, R. D., 294 Peris, F. S„ 249
Lauver, P., 18 Phinney, J. S., 55, 61
Lazarus, A. A., 249, 250 Piaget, J., 216, 220
LeShan, L., 76, 77, 78 Pigram, J. J., 95
Levine, S., 85 Pinderhughes, E. B., 26
Lewis, K. N., 26 Pitchford, R, 90
Lilleskov, R., 35 Pizzorno, J., 90, 93, 94
Lowen, A., 320 Polster, E., 249
Lucero-Miller. D., 61 Polster, M., 249
Lum, D., 65, 66 Ponterotto, J. G., 56, 57, 63, 64, 65, 68
Pope, K. S„ 318
Maclsaac, D. S., 29, 182, 185, 191, 195,
196,202, 203 Reid, D., 87, 90, 93
Mahoney, M. J., 74 Reid, W J., 26
Mahrer, A. R„ 75, 192 Richardson, N. F., 7, 42
Maslow, A. H„ 250 Richardson, T. Q., 63, 69
Matsumoto, D., 64, 65 Rinpoche, A. T., 77, 79
McClain, T. M., 92 Robbins, J., 87, 90
McDavis, K., 182 Roehl, E., 90
McEnroe, T., 7, 42 Rogers, C. R„ 184, 185, 250
McGrath, R, 57 Rohe, E, 90
Mehrabien, A., 182 Rokeach, M., 45, 47
Meller, P. J., 57, 65, 68 Rosenbaum, R., 250
Milliones, J., 62 Rossman, M.. 85
Millman, D., 87, 157 Rowe, C. E., 29, 182, 185, 191, 195,196,
Minuchin, S., 249 202, 203
Molinaro, K. L., 69 Rychlak, J., 250
Monges, M. M., 70
Morrison, J., 25, 28 Sanderson, C., 318, 319
Morten, G., 61 Sandler, J., 35
Moss, R. W, 94 Schiffmann, E., 81
Schwartz, G. E., 294
Nagy, T. L, 42 Schwartz, T., 73
Namyniuk, L., 56, 63, 70 Shaffer, D. R„ 220
Naparstek, B., 85 Sharma, P., 61
414 AUTHOR INDEX

Shulman, L. A., 28 Todd, J., 250

Siegel, H., 317 Triandis, H. C., 65, 68
Sigelman, C. K., 220
Simek-Morgan, L., 184, 185, 256, 279 Ullman, M., 75
Singelis, T. M„ 56, 57, 65, 68 Ulrich, R. S., 95
Smith, V. G., 200
Sodowsky, G. R., 57 Wachtel, R L., 128
Somer, E., 86 Walsh, W B„ 26
Sommers-Flanagan, J., 40 Webb, N, B., 33
Sommers-Flanagan, R., 40 Wedding, D., 250, 310
Sowers-Hoag, K., 27 Weeks, G. R., 250
Steinman, S. O., 7, 42 Weil, A., 81
Stern, D. N„ 202, 203, 294 Weiss, J., 253, 278
Stolorow, R., 266 Welfel, E. R., 185, 188, 191
Strauss, J. S., 193 Werbach, M. R., 86
Strupp, H. H„ 25, 26, 265 Wheeler, S., 73
Sue, D.W.61 Wilber, K„ 76, 248, 320, 366
Sue, S., 65 Williams, D. R., 73
Sunwolf, 68 Wirth, L., 55
Suzuki, L. A., 56, 65, 68 Wise, C. L., 57
Suzuki, S., 79, 103 Wise, S. L„ 63
Sweezy, M., 27 Wolf, E. S„ 28, 30, 184, 185, 192, 196,
Swenson, L. C., 25, 42 201, 202, 203, 205, 250, 266
Wolmark, A., 27
Taffe, R. C., 57
Takaki, R. T., 63 Young, M. E„ 309, 310, 311
Tarvydas, V. M., 41, 42, 46, 47
Taylor, J., 75 Zeig, J. K., 249
Teyber, E„ 196, 236, 249, 265, 267, 278 Zimmerman, N., 75
Thayer, R. E., 92 Zinn, H., 63
Subject Index

acceptance, 20, 24 Level Six, 299-300

accommodation, 217, 220 Level Seven, 300-302
acculturation, 60-61 Level Eight, 302-303
active listening (see listening) Level Nine, 303-304
adaptation, 217 affective development, 294-309
affect affective experience, 291-292, 320-365,
acceptance, 302-303, 383-386 365-396
assessment, 293 assessment, 295
conflicted, 299-300, 308-309 model for understanding, 293-309
dealing with, 311-319 Level One, 294
default, 298 Level Two, 296
exercises, 320-365, 366-398 Level Three, 296-298
overview, 322-323 Level Four, 298
identification, 367-368 Level Five, 298-299
intensity, 298-299, 379-380 Level Six, 299-300
labeling, 296-298, 367-368 Level Seven, 300-302
labels, 369-372 Level Eight, 302-303
samples, 370-371 Level Nine, 303-304
loss of control, 312-313 affective expression, 292, 365-396
mixed, 299-300, 308-309 assessment, 306
model for working with, 291-309 congruence, 308
screen, 301 model, 304-309
underlying, 300-302 Step One, 305-307
understanding, 303-304, 383-386 Step Two, 307
Affect Continuum Exercise, 299, 379- Step Three, 308
383 Step Four, 308-309
affective awareness, 291-292, 320-365, ritualized, 307, 309
365-396 American Board of Professional Psychol¬
assessment, 295 ogy (ABPP), 9
model for understanding, 293-309 anger, dealing with, 315-316
Level One, 294 anxiety, dealing with, 314-315
Level Two, 296 assimilation, 217, 220
Level Three, 296-298 attending skills, 101-125, 187
Level Four, 298 attunement, 189
Level Five, 298-299 authenticity, 25

415
416 SUBJECT INDEX

autonomy, 41 physical appearance, 105-106

awareness, cultural, 54, 55-61 timing, 113-114
use of physical space, 113-114
beneficence, 42, 48 competence, therapeutic, 36
Board certification in psychology, 6-7 conceptualization, 252-254, 255-256
Bodily Awareness Exercise, 299, 300, 321, concrete thought, 216, 219
333-340 confidentiality, 43
bodily experience (see physiological expe¬ limits, 43
rience) confrontation, 204, 256-264
Bodily Experience Exercise, 300, 321 guidelines for use, 259-260
advanced, 359-365 conscious competence, 17
basic, 348-359 conscious incompetence, 16—17
Body Attunement Exercise, 321, 340- consultation, 32
347 core affects (see patterns, affective)
bodywork, 320-365 countertransference, 30-34, 265-267,
boundaries, ability to set, 19, 22 271
breathing, 224-226, 313, 314, 383-384 countertransference
diaphragmatic, 78, 324-328 client-specific, 30-34
exercises, 77—79, 303, 321—333 issue-specific, 30-34
advanced, 329-332 red flags, 30, 31
basic, 324-328 stimulus-specific, 30-34
over-, 317 trait-specific, 30-34
under-, 317 creativity, 27
bridge exercises, 359-360 crises, cognitive-related, 223-226
burnout, 29 crying, dealing with, 313-314
cultural awareness, 54, 55-61
case conceptualization (see cultural bias
conceptualization) in diagnosis, 63
catharsis, 309-311 in language, 59
facilitation, 312 cultural competence, 52-69
centeredness, 77-83 cultural definitions of psychopathology, 63
code of conduct, 40 cultural identity, development, 59, 60
cognitive capacity, assessment, 221-222 cultural knowledge, 54, 61-65
cognitive complexity, 21, 23, 215-216 cultural self-awareness, 52-69
cognitive development, 216-222 cultural sensitivity, 52-69
encouragement, 220 traits, 56-57
stages, 216-217, 218-219 cultural skills, 54, 65-69
cognitive intervention communication, 65
building context for, 248-256 culture, 53
Step One, 249-250 defined, 52
Step Two, 251-252
Step Three, 252-255 decision-making
Step Four, 255-256 emotional, 44
cognitive strategies, hierarchy, 221 evaluative, 44
cognitive style, assessment of, 221-222 existential, 44
communication delay of gratification, ability, 22
aspects, 103-117 delusions, 225-226
kinesics, 106-110 depersonalization, dealing with, 317-319
nonverbal, 102-117 dissociation, working with, 317-319
paralinguistics, 110-112 dreamwork, 72-73
 SUBJECT INDEX 417

emotional awareness (see affective experience-nearness, 280

awareness) expertness, 23
emotional experience (see affective explanation, 191, 269, 280-283
experience) eye contact, 106-107 {see also ldnesics)
emotional expression {see affective
expression) facial expression {see kinesics)
emotional leaks, 359, 360 fairness, 42
emotional maturity, 23-24 fear of failure, 28
emotions {see affect) fear of newness, 28
empathic attunement, 27 fear of reaching out, 28
Empathic Communication Scale, 198- feeling words, 370-371
199 fidelity, 42
empathic failure, 25, 199-203 flexibility, 21, 23
optimal, 199-203 flight into health, 28
empathic immersion, 189 focusing relaxation {see relaxation,
empathic rupture, 202 focusing)
empathic skillfulness, 180-211, 269 formal operational thought, 216, 219
additive nature, 197-211
phases of the cycle, 186-194 guided imagery, 82
Phase One, 186-187
Phase Two, 187-189 habitual behavior {see patterns, behav¬
Phase Three, 189-191 ioral)
Phase Four, 191-192 habitual mode of relating, 33
Phase Five, 192-194 hallucinations, 225-226
empathy, 21, 180-211 Here-and-Now Affect Exploration
trait versus skill, defined, 180-183 Exercise, 299, 300, 369-379
versus blank slate, 185 here-and-now process {see process
versus co-experience, 183, 184 comments)
versus identification, 183, 184 hospital privileges, 9
versus intuition, 185 hostility, dealing with, 315-316
versus sympathy, 183, 184
versus warm fuzzies, 185 idealization, 203
encouragers, 156-158 imparting information, 226-235
nonverbal, 156 normalization, 228, 229-230
repetition, 156 psychoeducation, 228, 229
semiverbal, 156 relabehng, 228, 230-231
simple phrase, 156 informed consent, 43
encouraging phrases {see encouragers) inner experience {see affective
epistemological feeling, 25 experience)
ethical code {see ethics) inner work, 72-73
ethical standards {see ethics) intake interviewing, 149, 251-252
ethics, 21, 23, 39, 40 components of, 151-153
aspirational, 40-43 intelligence, 215-216
guidelines, 40 internalization, 199-203
mandatory, 40-43 interpretation, 191, 204, 269, 276-288
ethnicity, 53 guidelines for use, 279-283
defined, 52 timing, 280
ethnocentrism, 66-67 intimacy, capacity, 21
ethnorelativism, 66-67 introspection, 20, 24
experience-distance, 276 intuition, 25
418 SUBJECT INDEX

journaling, 72-73 technique, 80

justice, 42 mirroring, 203
moral principles (see morals)
kinesics, 106-110 morals, 39, 40
autonomy, 41
language, 367-368 beneficence, 42, 48
therapeutic use, 192-193 fidelity, 42-43
laws, 39, 40 justice, 42
least-restrictive-treatment alternatives, 43 nonmaleficence, 42
licensed clinical social worker, 5-9 veracity, 43
licensed marriage and family therapist, motor movement (see kinesics)
5-9
licensed professional counselor, 5-9 neediness, 29
listening nonmaleficence, 42
helpful hints, 125 nonverbal communication, 102—117
roadblocks, 118-121 congruence, 115
evaluative listening, 119, 121 helpful hints, 115-116
fact-centered listening, 120, 121 interaction with verbal communica¬
filtered listening, 119, 121 tion, 102-103
inadequate listening, 119, 121 accenting, 103, 104
rehearsing while listening, 120, 121 complementation, 103, 104
selective listening, 119, 121 contradiction, 102, 104
sympathetic listening, 120, 121 regulation, 103, 104
skills, 117-125, 187 repetition, 102, 104
substitution, 103, 104
meditation, 72-77 pitfalls, 112
positive consequences, 74 sensitivity, 115
technique, 74-76 synchrony, 115
mental health nutrition, 83-89
careers in, 3-9
career motivations, 10-16 openmindedness, 20, 24
desire for self-help, 11, 13 optimal empathic failure, 199-203
desire for status, 13, 15 outer expression (see affective expression)
desire to be needed, 11
desire to change world, 11-12 panic, dealing with, 314-315
desire to control, 13-14 paralinguistics, 110-112
desire to create meaning, 12 paraphrases, 158-164
desire to create purpose, H-12 guidelines for use, 159, 161, 168-170
desire to help, 10, 12 introductory stems, 160
desire to share experience of patience, 23
recovery, 13, 15 patterns
desire to share knowledge, 13-14 affective, 237, 265
desire to share wisdom, 13-14 behavioral, 237, 265
credentials, 4-9 cognitive, 236, 265
degrees, 4-9 interpersonal, 50-51, 52
academic, graduation pointing out, 235-240
requirements, 4-9 purpose, 237-238
disciplines, 4-9 relational, 236, 265
licenses, 5-9 physical activity, 89-90
mindfulness, 79-80 physical appearance, 105-106
 SUBJECT INDEX 419

physiological arousal, 384 guidelines for use, 159, 161, 168-170

physiological awareness, 294 purpose, 165
physiological experience, 296, 297, 298, relaxation, 77-83, 321, 383
333-334 exercises, 80-81
physiological exploration, 294 cautions, 384-386
physiological expression, 361, 368 preparation, 385-386
preoperational thought, 216, 219 focusing, 303, 393-397
prescription privileges, 9 guided imagery, 82
pressured speech, 224 progressive muscle, 386-393
process comments, 204, 264-276 release of information, 43
guidelines for use, 267-271 respect, 21, 24
opportunities, 271-273 responsibility, client, 45
professionalism, 21, 23, 39 rest, 90-91
progressive muscle relaxation, 303, 386- restatements, 158-160
393 guidelines for use, 159, 161, 168-170
psychiatric nurse, 8 introductory stems, 160
psychiatrist, 8 rights, client, 45
psychological associates, 5-9 rigid cognitive beliefs (see patterns,
psychologist, 5-9 cognitive)
clinical, 5-9
counseling, 5-9 schemata, cognitive, 217
psychometrician, 5-9 school counselor, 7
psychopathology, cultural definitions, school of thought (see theoretical
63 orientation)
school psychologist, 7
questions, 126-154 self-awareness, 36, 38-69, 71-77
assumptive, 130-131 cultural, 52-69
attacking, 134-135 individual, 38, 43-47
clarifying, 126-127, 128, 240-244 interpersonal, 38, 48-52
guidelines for use, 241-242 physical, 91-92
purposes, 241-242 self-care, 70-98
closed, 140-141, 142 self-esteem, 19-20
content diverse multiple, 139-140 self-exploration, 20, 24, 32, 71-77
controlling, 136 self-respect, 19-20
guidelines for use, 129-144 sense of competence, 19
intrusive, 136-137 sense of humor, 27
judgmental, 133-134 sensorimotor thought, 216, 219
open-ended, 126-127, 128, 144-149, space, utilization (see use of physical
240-241 space)
pitfalls to use, 129-144 speech (see paralinguistics)
pseudo-, 131-133 standard of practice, 40
purposes, 126 summarization, 173-177
shotgunning, 141, 143-144 guidelines for use, 174
suggestive, 129-130 systematic inquiry, 126-127, 128, 149-
tangential, 137-139 154, 240-241

race, 53 theoretical orientation, 189-190, 197,

defined, 52 205, 249-250, 278
recreation, 96-97 therapeutic neutrality, 25, 265
reflections, 164-168, 203-204 therapeutic responding, 155
420 SUBJECT INDEX

thought racing, 224 hindering, 27-31

timing, 113-114 fear of failure, 28
tolerance, 21 fear of newness, 28
touch, 113 fear of reaching out, 28
traits neediness, 29
definition, 18 transference, 265-267
facilitating, 19-27 treatment planning, 252-253, 255
acceptance, 20, 24
authenticity, 25 unconscious competence, 17-18
boundaries, ability to set, 19 unconscious incompetence, 16
cognitive complexity, 21, 23 understanding, 191, 269, 280-283
creativity, 27 use of physical space, 113-114
delay of gratification, ability to, 22
emotional maturity, 23-24 values, 39, 40, 43—48
empathy, 21, 26 central life, 47, 48
ethics, 21, 23 clinician-client dissimilarity, 44, 45
expertness, 23 contextual, 44
flexibility, 21, 23 emotional, 44
intimacy, capacity, 21, 26 essential, 47, 48
introspection, 20, 24 evaluative, 44
intuition, 25 existential, 44
openmindedness, 20, 24 instrumental, 47, 48
patience, 23 interpersonal, 49
professionalism, 21, 23 rapport, 45
respect, 21, 24 terminal, 47, 48
self-esteem, 19-20 values clarification, 39-52
self-exploration, 20, 24 ventilation (see catharsis)
self-respect, 19-20 veracity, 43
sense of competence, 19 verbal communication skills, 155-179
sense of humor, 27 vicarious introspection, 190
tolerance, 21
wisdom, 27 wisdom, 27
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