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Loving what may sting: In literature and in therapy

By Johanna Bond March 15, 2021

A good book has been a steadfast companion for me throughout my life. At times, literature has provided me with a reason to step back from a busy life and retreat into much-needed introvert space. Other times, it has given me a safe haven, the company of imperfect yet lovable characters, a deep emotional awakening of empathy or a connection to a part of myself that I hadn’t previously recognized.

When clients step foot in my office (or these days, click onto our telehealth sessions), I’m hoping to provide many of the same things that a good book has provided for me. I’m hoping they will feel heard and emotionally connected — to themselves as well as to me, their counselor. As counselors, I think it is important that we consider the parallels between the offerings of strong literature and the interpersonal healing connection of therapy. I say this because literature can be a solid complement to therapy, a tool for self-exploration, and also because of what literature can offer to us as imperfect humans ourselves. As a writer and editor in addition to being a counselor, I hold the connections between therapy and the written word close.

In the 2002 novel The Secret Life of Bees (my favorite novel), Sue Monk Kidd welcomes readers to accept things that could sting through writing that is full of gentle metaphor. She uses elements of the writer’s craft to highlight an “invisible claim” — the statement at the heart of the writing and the takeaway the writer hopes to share with the reader.

The invisible claim in Kidd’s novel echoes the work of therapy in many ways, and especially of Internal Family Systems (IFS) therapy. To further explore the parallels between therapeutic self-exploration and writing, I’ll focus on IFS.

As Richard Schwartz and Martha Sweezy write in their 2020 second edition of Internal Family Systems Therapy, this approach to therapy includes the concepts that everyone has internal parts, that all parts are valuable (although they can become constrained or burdened), and that everyone has at the core a Self with the ability to lead. Acceptance and curiosity are at the heart of IFS as a therapeutic approach. Those same things are at the heart of The Secret Life of Bees. Just as we may use various techniques in therapy to reach curiosity and acceptance, Kidd uses elements of writing to demonstrate loving the things that could sting us.

Diving into the beehive

In Chapter 5, white protagonist Lily and her Black companion Rosaleen find refuge with Black beekeeper August Boatwright and her sisters after running away from a racist-fueled incident and a harsh home. As 14-year-old Lily begins to come to terms with the accident that killed her mother years before and the complicated emotions she feels toward her family and herself, Kidd brings to light (or, perhaps, to dark) the depth of the characters, their interpersonal relationships and the impact of racism. Using the metaphor of beekeeping, Kidd introduces the reader to the invisible claim of loving the things that could sting us. Through this metaphor, in conjunction with Kidd’s use of darkness and place, readers are able to wade into the parallels between the elements of writing and the internal growth of the story’s characters.

In this chapter, Kidd begins to clarify the role of the bees who feature so prominently as a metaphor in the book. At the opening of the novel, and prior to arrival at the beekeeper’s house, Lily experiences bees buzzing in her bedroom. Each chapter opens with a different fact about beehives to set up the events to come. August, the primary beekeeper, shares with Lily the “bee yard etiquette”:

She should not be afraid, but “Still, don’t be an idiot; wear long sleeves and long pants.”
She should not swat.
She should whistle if feeling angry.
Above all, “send the bees love. Every little thing wants be loved.”

This is truly the heart of the novel, although readers might not know it yet because they have not fully encountered all the things that can sting. However, by discussing “bee yard etiquette,” August provides the framework to understand Kidd’s invisible claim that is interwoven through the novel: that we can (and should) love the things that may sting us; that even those dangerous things — outside of us, like the bees, or inside of us, like our emotions or our history — deserve love.

Into the darkness

The bees aren’t the only potential danger Kidd encourages readers to love; the dark, too, features prominently. The chapter opens with a statement of fact that if we were able to follow a bee into its hive, the first thing to which we would have to adjust is the darkness. After establishing that bees do their work in the dark, Kidd facilitates important moments for her characters in the dark too. As is clear when she writes of August letting “out a sigh that floated into the darkness,” and later when August and Lily walk back to the house when “darkness had settled in and fireflies sparked around our shoulders,” darkness provides a scaffold for letting go and experiencing gentleness after work time. In the dark, the characters are able to give freedom to their emotions and acknowledge their secrets.

At the end of the chapter, Lily walks by starlight to the wailing wall where she can acknowledge her feelings toward her mother and hopes to let them go. She says, “I … studied the darkness, trying to see through it to some sliver of light.” Although it’s not yet clear to Lily, Kidd is making it clear to readers that real sight will occur in the dark, not in searching for the light. In creating this awareness and sharing the character’s secrets, Kidd allows readers to feel that they are themselves akin to the darkness. Similarly, in therapy, we sit in our clients’ darkness with them and create the emotional space for them to develop insight.

Along with the literal darkness of night, Kidd uses the darkness of racism as an element of the story and an element of personal growth for Lily. It is noteworthy that Kidd addresses racism directly in the story while simultaneously writing about darkness (as mentioned above) in a way that does not vilify it. So much literature equates darkness with malevolence, grouping in gradients of skin color in the process. Kidd defies this norm by wading into the darkness of night openly and also through the growth of the protagonist’s racial awareness.

In this chapter, Lily overhears August discussing with her sister June the lack of acceptance others might have for Lily and Rosaleen, pointing out, “Who’s gonna take them in if we don’t — a white girl and a Negro woman? Nobody around here.”

Each character, including Lily, is aware of the impact of race. She becomes even more aware of it as she is surrounded by Black women and men in her new surroundings. She becomes aware of the racism around them, between them and within them.

Lily overhears June naming Lily’s whiteness to August and states to the reader, “This was a great revelation — not that I was white but that it seemed like June might not want me here because of my skin color.”

She later states, “Mostly I felt resentment at June’s attitude. … There was no difference between my piss and June’s,” and later still comes to share that “I felt white and self-conscious sitting there, especially with June in the room. Self-conscious and ashamed.”

Lily is aware of the human similarities between herself and June, as well as the differences and her own privilege as a white person. By exploring racism — with all its metaphorical stingers — Lily is able to better understand herself and fully engage in relationship with those around her, including June. In the course of a few pages, Kidd unpacks immense growth and personal exploration of Lily’s understanding of race, leading readers to understand racism as another aspect of the invisible claim.

In the midst of unpacking racism, Kidd uses interpersonal (and intrapersonal) relationships to deepen the invisible claim of loving what might sting. The Boatwright sisters demonstrate their love for one another even if they don’t always like one another, and August shows unwavering love through her welcome of Lily. In return, Lily acknowledges that “I wanted to make her love me so she would keep me forever.”

Initially, Lily does not accept herself in an attempt to be loved by August; however, she later uses August’s acceptance as a model to accept herself. This is first shown through Lily’s acknowledgement of her anger and grief toward her mother at the end of the chapter, when Lily visits May’s wailing wall. She states, “Placing my hands on the stones, all I wanted was not to ache so much.” But instead of pushing off her feelings, she places a paper with her mother’s name into a cranny in the wall. Lily is beginning to accept the difficult emotions and the pain that goes with them, just as August and the other sisters work to accept and love one another despite the potential for pain.

Similarly, in IFS therapy, clients get to know their internal parts, including the parts that have the potential to sting. As counselors, we are able to model acceptance and curiosity, two things that clients may begin to develop themselves toward their internal parts. And as healers, we are constantly doing our own work to accept our internal parts and emotions.

Each detail of Kidd’s writing reflects the invisible claim, including the places featured within the chapter. Two of the main locations of the chapter represent acceptance for an emotion or activity. First, the reader learns of May’s wailing wall, where May (and later Lily) write out their troubles on pieces of paper and tuck them into crevices between the rocks. The wall is created for May to have an outlet for grief and becomes a symbol for grief and sadness; the characters are able to accept these difficult emotions by connecting with the wailing wall. The second place is at the beehives, where Lily and August face the danger of bee stings and the anger that can cause them.

Each of these places has a difficult emotion or activity associated with it, but each also holds the potential for growth by engaging with the place. The wailing wall allows for an acceptance and letting go of grief, whereas the beehives allow for tolerance of anger and room for love at the same time.

Kidd engages with the typically danger-ridden metaphors of bees and darkness (literal darkness, as well as the darkness of racism and internal difficult emotions) and invites readers to explore them in the same gentle manner that August welcomes Lily and Rosaleen to her home. In bringing to life place and metaphor, Kidd clearly states the invisible claim that the difficult things around us and within us — the things that we think may sting or harm us — are actually worthy of love and can facilitate growth. Kidd weaves the invisible claim in seamlessly with the narrative, leading readers through a metaphorical parallel to the action and character growth taking place in the chapter.

These elements of writing — the use of metaphor, darkness, relationships between characters, and place — each enhance the emotional souvenir of the book of loving the things that could sting us. In therapy, we are working to achieve the same outcome with our clients, although in therapy, the things that may sting are often internal parts of one’s self.

What’s on your bookshelf?

Diving into these details of the text further enhanced my own understanding of why I connect to the book’s characters and to the enticing darkness of which Kidd writes. I’ve shared The Secret Life of Bees with clients as an adjunct to the work we are doing, in order to process what they might connect with in the text.

I encourage other therapists to look at their bookshelves and consider which works of fiction (or poetry or any other genre) have had an impact on them as a person. What about those books resonated with you? Considering this can be useful for your own self-exploration and may also provide insight for your work with clients.

My love of reading augments my work as a counselor. Not all literature requires an in-depth explication to understand its impact on the reader. And not all literature coincides as neatly with therapy as The Secret Life of Bees. That being said, I highlight these details of Kidd’s writing to show how we can use the elements of literature to better understand the work we do and the depth of our own humanity.

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Johanna Bond is a licensed mental health counselor at Perspectives Mental Health Counseling PLLC (perspectivesroc.com) in Rochester, New York. She also works as a freelance editor at Perspectives’ Pen, offering editing services for creative, academic and therapy-focused writing. Her writing has been featured on The New York Times Well blog and HuffPost, and she currently blogs for Psychology Today. Follow for more updates at johannabond.com or on Twitter: @johannambond.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Learning from highly effective counselors

By Sidney Shaw March 10, 2020

The term “supershrink” has been used to refer to counselors and other mental health professionals who are very good at what they do and who attain significantly better client outcomes than average. It is perhaps not surprising that such a witty and playful term would come from an adolescent.

In the early 1970s, David Ricks conducted an analysis of the long-term outcomes of “highly disturbed” adolescents treated in a metropolitan guidance center. In this center, some of the youth had labeled one provider “the Supershrink.” Upon subsequent data analysis, Ricks found that adolescents who received treatment from this provider had significantly better long-term outcomes than did those who saw another provider. Turns out that the teens were right; the provider was a supershrink.

The idea that some counselors are exceptional and have very high success rates with clients is not new. In fact, this phenomenon has been verified empirically. Research over the past several decades has demonstrated that some counselors consistently achieve higher client improvement rates than do other counselors. With that in mind, it is important to consider what we can learn as counselors from so-called supershrinks and how we can embody the characteristics and actions of highly effective counselors to improve our own effectiveness.

Counselor effects and outcome research

The term “therapist effects” or “counselor effects” refers to variation in counseling outcomes that are attributable to the counselor, in contrast to other factors such as techniques or theories that contribute to counseling outcomes. Findings of counselor effects appear in a variety of study settings such as naturalistic clinic settings and in randomized clinical trials (RCTs). Counselor effects in RCTs are particularly intriguing because these studies are tightly controlled. In RCTs, counselors commonly adhere closely to a treatment manual (i.e., following specific steps in adherence to a specific theory), and there is also control for client severity. RCTs are the gold standard for comparing efficacy of specific treatment approaches for specific disorders.

Although there have been important findings about the efficacy of different treatment approaches or theories from RCTs, another finding that has received less attention over the years is that counselor effects are the better predictor of counseling outcomes. In other words, who the counselor is makes more of a difference in terms of client improvement than does which theory the counselor professes to use. It is impossible to completely disentangle counselors’ characteristics and actions from the theories that they use, but meticulous research and meta-analyses by renowned researchers such as Bruce Wampold have indicated that counselor effects are up to eight times stronger at determining client outcomes.

As Wampold and others have pointed out, these findings about the relative strength of counselor effects in comparison with theoretical approach are not justification for tossing out counseling theories. Framework, structure, a road map for navigating clinical territory, and conceptualization are just some of the benefits of grounding our work in theories of counseling. That said, outcome researchers have for decades focused predominantly on comparing different theoretical approaches while giving relatively little attention to a more powerful factor — the characteristics, pan-theoretical practices/actions, and attributes of the counselor.

Five characteristics and actions of highly effective counselors

Although the existence of counselor effects in outcome research has been around for several decades, empirical attempts to discern pan-theoretical characteristics and actions of highly effective counselors are rather new. There are limits to developing a list of such characteristics because new research is frequently emerging. In fact, it is noteworthy that the five characteristics highlighted in this article are just some of the major characteristics and actions of highly effective counselors.

The list contained here is composed of qualities that counselors can actively cultivate in their current practice. In other words, there are some strategies for growth with each of these five qualities. There are other characteristics of highly effective counselors in the research literature for which it is not currently clear how to increase or enhance those characteristics (e.g., attachment history, facilitative interpersonal skills). Thus, this list focuses on characteristics and actions that can be enhanced to improve counselor effectiveness. Accompanying the descriptions of these characteristics are some tips for developing each of them in your own counseling practice.

1) Presence and
2) countertransference management

The counselor’s “way of being” serves as a vehicle through which therapeutic actions and interventions take place. Two related concepts from the counselor effects research that speak to the counselor’s “way of being” and “way of relating” are presence and countertransference management. Both concepts have theoretical roots.

For instance, in the existential-humanistic tradition, presence refers to counselors being “in the moment,” connected with clients’ experiences and their own, and fully engaged in the I-Thou relationship with a client. Presence can also be defined by identifying it as the opposite of absence (e.g., distraction, boredom, disconnectedness, remoteness).

Countertransference, of course, has theoretical roots in psychoanalysis. Sigmund Freud considered it to be when a client’s transference activated a counselor’s unresolved childhood conflicts. More broadly, a totalistic view of countertransference is that it encompasses all the counselor’s reactions to the client. Although countertransference reactions are commonplace, the impact of countertransference on counseling outcomes is largely due to how the countertransference is managed. Meta-analytic research by Jeffrey Hayes and colleagues has indicated that successful management of countertransference predicts better counseling outcomes. Similarly, presence has been described by Shari Geller and Leslie Greenberg as a “prerequisite for empathy,” and counselor empathy is a strong predictor of client improvement.

Multiple factors can lead counselors toward increased presence and better countertransference management, including self-insight (e.g., awareness of self in relationship, cognitive and emotional awareness), anxiety management, intentionality and mindfulness. Given all these factors, counselors can be left feeling a bit overwhelmed by methods to strengthen their presence and countertransference management. Fortunately, research evidence supports a few overlapping practices to enhance both of these qualities.

> Meditation/mindfulness practice: Sustained and consistent meditation practice has been shown to increase effective countertransference management, promote emotion regulation and nonreactivity, sharpen awareness and increase presence. Many different types of meditation and mindfulness practice exist. Counselors are advised to investigate these practices, to choose a practice aligned with their own preferences, and to maintain a consistent mindfulness practice.

> Self-insight and anxiety management: Counselors should work on their own psychological health and consistently practice self-observation and self-reflection. This can be done in supervision, in one’s own experience as a client, and through deliberate planning aimed at increased self-awareness.

Relatedly, anxiety management is an important component of countertransference management and presence. Although it is not unusual for counselors to experience anxiety within sessions, unmanaged anxiety can have untoward effects on a counselor’s presence, ability to manage countertransference reactions, and the therapeutic alliance. A first step is developing sensitivity to noticing anxiety when it appears. Second, counselors likely already have anxiety management skills (e.g., behavioral, cognitive, mindfulness-based) that they use with clients. Counselors can apply these skills to themselves.

> Pre-session centering: A study by Rose Dunn and colleagues revealed that counselors perceived themselves as having higher levels of presence when they engaged in a brief mindfulness centering exercise within five minutes of a counseling session. Additionally, clients perceived the sessions to be more effective when the counselor used the mindfulness exercise prior to the session. The basics of the centering exercise are consistent with acceptance and commitment therapy principles.

In this case, counselors would simply sit comfortably with a straight spine, take and notice gentle and full breaths, notice physical sensations, notice thoughts that emerged, acknowledge the existence of those thoughts and allow them to be present, imagine creating additional space for the thoughts with each breath, and then let go of focus on the thoughts to broaden attention to the environment around them. In this mindfulness approach, counselors aimed to accept the thoughts and experiences as an observer rather than clinging to or pushing away those thoughts. For more detailed information on mindfulness and acceptance centering, I recommend the work of John Forsyth and Georg Eifert.

> Self-care: This term is frequently discussed in our field, and self-care activities can vary greatly among individual counselors. It is important for presence, countertransference management and multiple other reasons that counselors engage in consistent self-care actions. One self-care behavior that seems relatively universal, and which has an impact on attention (i.e., presence) and emotion regulation, is sleep. Practicing healthy sleep hygiene (keeping room temperature at 62-68 degrees, sticking to a consistent sleep schedule, maintaining a dark environment, having technology limits at night, etc.) can provide conditions that are favorable for increased presence and greater countertransference management.

3) Professional self-doubt

The essence of this quality of highly effective counselors is captured in the title of an article by Helene Nissen-Lie and colleagues: “Love yourself as a person, doubt yourself as a therapist?” At first glance, the idea of professional self-doubt may seem like an unproductive place to be as a counselor. However, if we consider just a basic definition of “doubt” (i.e., to be uncertain), then the benefits for clients become clearer.

Counselors who possess certainty that they are helping a client are likely closing the door to self-critique and thoughtful consideration of ways to improve their work. Indeed, several studies by researchers such as Corinne Hannan and others have indicated that counselors consistently overestimate the effectiveness of their work with clients. Regarding self-doubt, two studies of experienced counselors by Nissen-Lie and colleagues revealed that counselors higher in professional self-doubt had stronger alliances with clients and higher levels of client improvement than did counselors lower in professional self-doubt.

Importantly, a third study by Patrizia Odyniec and colleagues showed that increased professional self-doubt among trainees/students resulted in poorer client outcomes than did lower professional self-doubt. One explanation for these findings is the difference in developmental stage of the counselors. Experienced counselors likely have higher confidence in their basic skills as counselors. Thus, professional self-doubt about their effectiveness can be beneficial as they strive for improvement due to their own uncertainty about client outcomes. In contrast, high professional self-doubt among trainees may be debilitating because of their earlier stage of counselor development and lower confidence in their basic counseling skills.

All that said, there appear to be clear benefits for clients when experienced counselors cultivate professional self-doubt. Here are some strategies for doing that.

> Prevent the “overconfidence effect.” This concept from social psychology is particularly relevant here due to numerous studies that have shown that counselors commonly overestimate whether and how much their clients are improving. Just being aware of this tendency to inflate their own client success rates can help counselors become increasingly humble and self-reflective about their effectiveness. Consciously questioning our own self-serving biases is an important step in maximizing client improvement rates.

> Monitor your effectiveness. Counselors should use some type of outcome measure (e.g., Outcome Rating Scale, Clinical Outcomes in Routine Evaluation-Outcome Measure, Outcome Questionnaire-45) to assess the degree to which their clients are improving or not. Routine outcome monitoring has repeatedly been found to improve client outcomes, and concrete client reports of their improvement level can help keep counselor overconfidence in check. Additionally, outcome monitoring can promote the beneficial stance of professional self-doubt because awareness of clients who are not improving or who are deteriorating
can lead counselors to act intentionally to improve.

> Love yourself as a person. An important caveat in the studies by Nissen-Lie and colleagues is that counselor self-doubt can improve client outcomes more when coupled with what is referred to as a “self-affiliative introject.” In general, this refers to higher levels of self-affirmation, self-love and self-acceptance. When a self-affiliative introject or self-affirmation is an area of struggle for counselors, it can affect their work with clients and their capacity to embrace professional self-doubt. Steps to build and strengthen a self-affiliative introject or stronger self-affirmation could include self-help, support groups or personal counseling.

4) Deliberate practice

Deliberate practice, a concept that originates in the expertise literature from researchers such as Anders Ericsson, refers to intentional and individualized exercises and actions aimed at strengthening specific areas of one’s performance. Early research on deliberate practice examined its effects in noncounseling domains such as chess, music and sports, to name a few.

In counseling, a promising study by Daryl Chow and colleagues of more than 1,600 clients working with 17 counselors found that the top quartile of counselors (i.e., those whose clients showed the most improvement) spent nearly triple the amount of time engaged in deliberate practice than did counselors in the lower quartiles of client improvement. Consistent with some previous research, Chow and colleagues found that the following factors were not significantly related to client outcomes: counselor age, professional discipline, gender, years of experience, highest qualification level and theoretical orientation. Below are some core components of deliberate practice combined with recommendations for integrating them into your counseling practice.

> Establish your baseline. To improve as a counselor and to determine if you are increasing effectiveness over time, you need to know how effective you already are with your clients. Routine outcome monitoring is a way to establish a baseline. Using an outcome measure and then tracking your client improvement rates over time is an initial step in deliberate practice.

> Record sessions with difficult or stalled cases. While not intrinsically motivating, we stand to learn a lot about areas for improvement with cases in which our weaknesses are most evident. Video recording is simple these days, and it is an indispensable tool that is not just for practicum students. Video recording can help counselors identify gaps in awareness and skills that simple self-reflection alone is unlikely to reveal. Relying only on our self-assumed clinical wisdom by mentally reflecting back on a session is unlikely to interrupt and change unhelpful patterns that may have emerged outside of our conscious awareness.

> Work with a consultant or consultation group. Stepping out of our own perspective and potential for self-serving biases is a critical ingredient of deliberate practice. By working with a competent consultant or consultation group, we can obtain diverse perspectives on our areas of weakness as counselors and thus develop specific goals and plans for growth while receiving ongoing support and feedback.

> Develop clear, targeted goals. Our goals need to be very clear and specific. It is not very effective to set a goal to “improve as a counselor.” Instead, a first step here would be to identify specific areas for potential growth as a counselor. This could be done in collaboration with your consultant/consultation group. With deliberate practice, the real growth takes place outside of actual client sessions. Outside of session, you have time, support and opportunity for reflection and practice as you engage in intentional efforts to develop new therapeutic skills or “ways of being” with challenging cases.

The specifics of deliberate practice are very detailed. Thus, counselors are encouraged to read the works of scholars such as Daryl Chow and Scott D. Miller on this topic for a more comprehensive review.

5) Multicultural orientation

Multicultural orientation is a rather new construct that differs from multicultural competencies. As described by Jesse Owen and colleagues, multicultural competencies are considered a “way of doing,” whereas multicultural orientation is a “way of being.” Multicultural orientation is a way of being that communicates the counselor’s
attitudes and values about culture to the client. Specifically, multicultural orientation consists of three overlapping pillars. Each of the pillars is described below and accompanied by recommendations for strengthening it in your counseling practice.

> Cultural humility: This refers to an interpersonal stance that is “other oriented” and open to understanding the client’s cultural experience and background. In addition to this interpersonal dimension of cultural humility, there is also an intrapersonal dimension in which counselors have an openness and eagerness to reflect on their own limits and blind spots in understanding the cultural experience of another. Four studies with more than 3,000 clients have found a significant positive correlation between client ratings of their counselor’s cultural humility and counseling outcomes. An important consideration here is that the “client’s perception” of their counselor’s level of cultural humility was related to client outcomes.

There are some strategies and actions that counselors can take so that clients are more likely to experience them as being culturally humble. First, given the intrapersonal domain of cultural humility, counselors are encouraged to self-reflect upon and analyze their own areas of potential biases and cultural blind spots. Pamela Hays’ “ADDRESSING” model can be a useful framework for determining domains in which a counselor has a privileged status because these domains of privilege are likely sources of blind spots.

Second, counselors are encouraged to broach the topic of culture at the intake session with clients in an open-ended manner. This strategy also overlaps with the pillar of “cultural opportunities” (broaching strategies will be described in that section).

Third, counselors should check in with clients frequently to ensure that they accurately understand the client’s cultural perspective. This “cultural check-in” should be one part of a broader culture of feedback that is created by the counselor in the session. Specifically, counselors need to acknowledge with clients that they strive to understand clients’ perspectives and cultural experiences, but despite their best efforts, they may sometimes misunderstand. Openly and repeatedly inviting clients to provide candid feedback (especially negative feedback) is a way to express humility and to make repair attempts if and when a counselor misunderstands or unknowingly commits a microaggression.

> Cultural opportunities: This pillar refers to opportunities in sessions for the counselor to broach the topic of culture with a client. Importantly, research on this topic indicates that “missed cultural opportunities” (i.e., the client’s perception of the counselor missing and not acting on opportunities to discuss/broach culture) are negatively correlated with client outcomes. In other words, as the counselor misses more cultural opportunities, client improvement declines.

One way to enhance the positive effects of cultural humility and cultural opportunities is for counselors to broach the topic of culture at the intake session. For example, “How does culture influence the problem?” The purpose of such an open-ended question is to better understand the client’s perception of culture. If clients are unclear about what is meant by “culture,” alternative phrasing ideas can be gleaned from the “Cultural Formulation Interview” in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The interview offers numerous examples for asking open-ended questions about clients’ cultures.

Broaching or inquiring about the influence of culture should not be limited to the intake session. Counselors need to attentively engage with clients to understand how they
see the role of culture as sessions progress. This can lead counselors to sensitively seize upon cultural opportunities in sessions in a way that resonates with clients.

> Cultural comfort: The final pillar of multicultural orientation is counselors’ level of openness, ease and comfort in working with diverse clients and engaging with clients about the topic of culture. In a 2017 study, Owen and colleagues found that counselor cultural comfort level predicted client dropout rates. Higher levels of counselor cultural comfort were associated with lower client dropout rates. This is particularly important given that a high dropout rate is one of the more pernicious challenges for our field to address. Indeed, a 2012 meta-analysis by Joshua Swift and Roger Greenberg found that the average dropout rate in counseling is 20%.

In terms of counselors increasing their cultural comfort levels, some of the strategies mentioned for cultural humility and cultural opportunities (e.g., intentionally reflecting on/analyzing biases and blind spots, broaching the topic of culture in sessions) can apply. One additional strategy that can help in this regard is role-playing and rehearsal — specifically, role-playing with colleagues in which the counselor practices engaging with mock clients around the topic of culture. Counselors are advised to practice broaching the topic of culture in situations that represent a wide range of challenge. For example, if a counselor has had little or no contact with clients who are transgender, then role-playing a scenario in which the counselor broaches culture with a mock client who is transgender would be a way to expand the counselor’s cultural comfort. Inviting and receiving feedback from colleagues in such mock sessions is essential for counselors to expand and enhance their broaching skills and increase their level of cultural comfort.

Conclusion

The number of factors that contribute to effective counseling is vast and incalculable. As research continues to evolve on this topic, we develop a richer understanding of some of these factors. We now have abundant research support for counselor effects and the relative strength of these effects in comparison with theoretical techniques.

The lines between counselor characteristics, common factors (e.g., therapeutic alliance, placebo effect) and specific factors (e.g., treatment interventions, techniques) are not neat and discrete. Instead, each of these has some overlap with and multidirectional influence on the others. That said, recent research indicates that the characteristics, qualities and pan-theoretical actions of counselors are prominent in potentiating the therapeutic alliance and theoretical techniques to improve client outcomes.

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Sidney Shaw is a core faculty member in the clinical mental health counseling program at Walden University and a certified trainer for the International Center for Clinical Excellence. Contact him at sidneyleeshaw@gmail.com.

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Technique without soul is dead

By Peter Allen December 10, 2019

As a licensed professional counselor, I am interested in what is helpful or effective for my clients. As a client in therapy, I am equally interested in what helps me to reduce my own suffering and develop better skills for navigating the larger world in which I live. Therefore, I consider myself a student in both respects. The clinician in me studies to achieve greater skill and experience, whereas the client side of me is ever sensitive to what is helpful in everyday life. I have had many experiences as both clinician and client that inform my approach, depending on which chair I happen to be sitting in on any given day.

There is one particular experience I had in therapy that has taken me years to integrate and use toward positive ends. At the time, I had been seeing a therapist for a few weeks. I was there to work through some old resentments and anger that were bogging me down and interfering with what was an otherwise good life. A trusted colleague and friend had referred me to this particular clinician, an older man with years in the field and a positive reputation.

After a few sessions, I remember thinking that the therapist was a little aloof for my tastes and perhaps a bit too professorial. He was kind but in a detached way. I had the sense that he did not think about me or my problems after he left the office for the day. Reflecting on my experience with him, I realize it was not what he did that sticks in my memory so much as how he taught me what not to do.

I had been attempting to work through some of my aforementioned anger issues with his help but had become somewhat stuck. He gestured toward a large, cube-shaped pillow on the ground in his office, measuring roughly 3 feet on each side. I hadn’t paid this object much attention until that moment, which is strange because a large cubed pillow in any office strikes me as noticeable in hindsight. The therapist asked me to repeatedly strike the pillow while verbalizing the very things that were upsetting me. I looked at him incredulously, and I remember specifically thinking, “This is stupid.”

I voiced my reservations, telling him openly that I did not think hitting a pillow and venting my anger in this way would be of much help. He smiled at me, trying to be reassuring, and encouraged me to try the exercise despite my misgivings. And so, I did.

Not surprisingly, I felt stupid. I was a grown man standing in a quiet therapy office hitting a large, cube-shaped pillow and trying to muster real anger in hopes that it would overtake my embarrassment. It did not. It caused me instead to feel like a petulant child who was not getting his way. Later, I would in fact feel the anger that was elusive in that moment, but my anger would be directed at the therapist rather than at the other people in my life.

What went wrong?

We processed this event immediately afterward in a somewhat perfunctory way, owing to my new resentment toward the therapist. I told him that I felt stupid, and he listened without comment. He was less interested in how the exercise reflected on him and more interested in my experience of it. The session ended on an anticlimactic note. I left his office and decided not to return. I should note that I could have given him more decisive verbal feedback about my experience, or inquired further about his intentions or technique. I did neither of those things, so in a way, perhaps I cheated him out of an opportunity to learn and grow. I take some comfort in the thought that his training and development were not my responsibility.

Upon reflection, I came to see that this therapist had disregarded valuable information and feedback I had given him in session. He used an intervention with me that he had likely used countless times before with other clients, and perhaps with some success. After all, he had gone to the trouble of purchasing that strange cube-shaped pillow. He executed a technique despite my obvious resistance because he thought he knew better than I did about what might be helpful. My experience was that I felt unimportant, unheard and embarrassed.

After reflecting on this somewhat minor event, I finally came to understand some of the dynamics that had played out in that room. The therapist was applying a technique without any soul — or, in other words, without first establishing an emotional bond or connection with me. Because he had not forged such a connection with me, the intervention was an abject failure. He assumed that the technique alone was powerful enough to overcome my reservations or, as I’ve said, that he knew better and I just needed to trust him. In my attempt to be the good client, I placed my trust in him, and he showed me that he had not earned it yet.

A basic critique I have of this method is that it does not translate to my life in the world. Hitting objects when one is angry has no application in the real world. We cannot repeatedly hit the table if we become angry in the middle of a corporate board meeting. This method is not encouraging the development of further skills; rather, it is reinforcing a negative human behavioral habit.

Although it took me many years to understand what I had experienced in that therapy session, I eventually arrived at an obvious answer: I went there assuming the therapist was, in fact, an expert, but the person who instructed me to hit the pillow was simply a flawed human being using a flawed methodology. He, like me, is in the process of learning and growing, and, as such, he is still making mistakes. I accept this, and I accept him as being in process.

Cause for reflection

Being on the receiving end of this intervention gave me license to truly examine its effectiveness, or lack thereof, in my own life. This small experience also led me to reflect on how often I — and perhaps, we, as clinicians — may be deploying techniques in a mechanical and disconnected fashion, whether we learned these methods in school, from a trusted mentor, or from a celebrity therapist. I have come to believe that when we do this, we are elevating and accenting the academic concept at the expense of an interpersonal connection.

What benefits our clients is subject to debate, of course, and reasonable people can disagree about this. We learn a variety of evidence-based practices, techniques and theories in the hope that we can help reduce our clients’ pain and suffering. I have colleagues I trust and respect enormously who approach therapy from a more scientific standpoint. They have a toolkit of interventions they use for a variety of presenting problems. Presenting problem A gets intervention B and so on and so forth. I also know brilliant clinicians who use a primarily interpersonal approach, in which the central and ongoing interventions are kindness, consistency, nonjudgment and acceptance.

I would be willing to gamble and say that the majority of therapists artfully blend the scientific with the interpersonal. What is scientific in counseling is by definition methodical, detached and concerned with evidence. What is interpersonal is by definition emotional, involved and subjective. There need not be tension between these two concepts; skillful therapists braid them together.

Carl Rogers, the founder of client-centered therapy (also known as person-centered therapy), came to the conclusion that the interpersonal approach actually produces scientific, measurable results. I will not dive too deeply into discussions of duality and what the superior approach might be (in part because I don’t know), but it is incumbent on the professional counseling community to ascertain anew each day what is effective versus what is ineffective.

My conclusion was that my therapist at that time was relying on pure scientific technique, which lacked warmth. Therefore, what I experienced was his detachment from me and his failure to respond to the verbal and nonverbal feedback I was conveying to him in that moment. My bias, of course, is the golden thread in this entire experience: I lean mostly Rogerian as a counselor, and my therapist had failed to honor one of Rogers’ most important insights — namely, that I am the expert on myself. My therapist put himself in the role of expert, which was a natural result of his unique life experiences, training, upbringing, biases and blind spots.

Undoubtedly, this therapist’s approach has been helpful and effective for many people over the decades that he has been in practice. With the enormous variety of human beings on this planet, an enormous variety of styles and approaches in counseling is merited.

I have concluded from this experience that technique without soul is dead. The cold application of scientific knowledge in the therapy office lacks humanity. However, using only warmth and empathy without technique can be amorphous and ungrounded. I occasionally find myself wanting to revert to technique alone for its definitive attraction — namely, that it is an intellectual and finite concept and therefore seems easier to grasp. Conversely, when I rely too heavily on an interpersonal connection, even as a Rogerian, I find this to be limiting in a different way.

For me in my process of development now, the interpersonal connection is what builds trust, and that is what allows techniques to flourish and gain traction. When techniques are successful and helpful, and when clients experience real change from them, the interpersonal connection thrives. In this way, a skillful pairing of these approaches serves to reinforce the strength of both of them.

I have tremendous empathy for my previous therapist, despite my obvious critiques of him. It was easy for me to see, both then and now, that he meant well. I also have the benefit of being able to evaluate his approach, whereas my own approach is not subject to his scrutiny. I have an inherent advantage in this sense because nothing I have done is under the microscope. That being said, readers of this article may find fault with my analysis, and I welcome a robust debate. I am grateful to him in a noncynical way for showing me what type of therapist I do not want to be: detached, professorial, expert. I strive to become more and more who I want to be as a counselor: someone who is involved, humble, and allied with my clients. In short, I strive to become the professional whom I needed that day in his office.

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Peter Allen is a licensed professional counselor at East Cascade Counseling Services in Bend, Oregon. Contact him at peterallenlpc@gmail.com.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

What does therapy mean to you?

Compiled by Bethany Bray June 11, 2019

What does therapy mean to you?

Jessica Ferrence, a licensed professional counselor (LPC) in Fayetteville, North Carolina, was a little taken aback when a client posed this question to her in a session. However, it sparked Ferrence’s interest and led to some self-reflection.

Therapy is what counselor practitioners do – but it means something different to each professional. It’s a place for the client to heal, grow, be vulnerable, set goals, get to know themselves and many, many more things.

For Ferrence, therapy is a place to uncouple oneself from pain and find strength.

“Therapy puts people in a vulnerable position because we trust clinicians with our deepest, darkest, most painful secrets; things we haven’t shared with our partners or family members or best friends for various reasons. When we feel safe enough to let down our walls — when we share the burden we’ve been shouldering for years or relive the experiences that haunt us in our dreams — we find the strength to find our voice,” says Ferrence, who considered the topic both as a practitioner and recipient of therapy. “Confronting our pain and reclaiming our lives, without fear of judgment or ridicule, can be extremely cathartic. We feel validated, understood and accepted for the first time in a long time — and maybe even ever. And that’s when healing truly begins. That’s when we realize that the power to break free from the grip of our past lies within us. That our vulnerabilities are no longer vulnerabilities, but rather areas of strength that we draw from. [It’s] where the image of our best self has come into focus, and more importantly, that we have the courage to turn that image into a reality.”

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CT Online asked a sampling of American Counseling Association members to consider the question “What does therapy mean to you?”

Read their thoughts below, and add your voice to the conversation in the comment section at the bottom of this page.

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As a therapist, to me, therapy is…

An honor and privilege. I continue to be humbled by the fact that my clients share with me their most sacred stories. Often these are trauma stories, in which their deepest pain and vulnerabilities lie in the details they have shared with very few, or only with myself.
A collaboration between the client and myself. My clients bring their expertise about themselves and their experiences. They bring their stories. They also bring their strength, resiliency and all of themselves – shadow and light. As a therapist, I bring years of clinical experience and education. It is my responsibility to provide a safe, non-judgemental and compassionate space for us to work in. As appropriate, I will offer clients my perspective, as well as evidence-based interventions and information, which they have the right to accept or decline freely, based on what fits for them.
An opportunity to support clients in reaching their goals. These goals might involve learning how to cope with the aftermath of loss or trauma, or learning how to manage distress related to stress and/or a mental/physical illness. Sometimes we are working together to adjust their understanding and expectations regarding healthy relationships and boundaries.
Often focused on helping clients to recognize that they deserve to be loved, respected, cherished and protected — and that in life they don’t need to be perfect to be “good enough,” but rather they only need to be perfectly themselves – with all of their disappointments, triumphs, strengths and vulnerabilities. Frequently, I find [therapy] is about helping clients learn to view themselves from the perspective of their wisest and most compassionate selves.
A place to educate and normalize my client’s reactions and/or symptoms, so that they can get a handle on what it is they are dealing with, what they might expect and strategies they might wish to consider to help them to better manage their distress.
A place in time where clients do not have to wear masks or say they are “OK” when they are not. A refuge. A place where their distress will be heard and witnessed by another human being, who will not judge, but rather will reflect back their distress without minimizing, and will also hold up a mirror to their strength, courage and tremendous resiliency.

Shirley Porter, a registered psychotherapist and a registered social worker in London, Ontario, Canada

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To me, therapy is for everyone. It is the opportunity for individuals to get the most out of life.

Though traditionally viewed as a medium for helping someone work through a particularly challenging issue or mental health disorder, therapy offers much more. The reality is that, yes, everybody struggles at various points throughout life and may benefit from some additional assistance. People need not wait, however, until life becomes challenging to seek therapy. That is, effective therapy may help people go well beyond attaining life satisfaction to the point of thriving.

Accordingly, the lens through which counselors view clients should be one that extends well beyond problem resolution. By resolving an issue, a person may shift from a bad place to a neutral one. Pushing beyond this is where we really begin to witness existential growth. This is the place where life satisfaction increases, interpersonal relationships improve, goals are achieved and one begins living a life that — until therapy — seemed unattainable.

As counselors we make the unattainable attainable. While I have yet to meet a new client who comes into the office under the premise of “My life is great, and I am here to make it even better,” counselors have the tools to do just that! When working with clients, then, my thought process is to first help address the presenting problem, then facilitate a personal growth process that exceeds previously thought of expectations.

This is one way, of many, that we may continue to destigmatize the therapeutic process. Therapy is not just for individuals with mental illness or problems—it is for everyone.

Matt Glowiak, a licensed clinical professional counselor (LCPC), certified advanced alcohol and other drug counselor, full-time clinical faculty member at Southern New Hampshire University and co-founder/co-clinical director of counseling speaks in Chicago, Park Ridge and Lake Forest, Illinois.

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By definition, therapy is sitting in a room with an essential stranger and discussing your inner most intimate memories, feelings and traumas. Sounds fun right?

No.

So, if therapy isn’t always fun, why do so many people continue to go and find such benefit from the process?

Everyone’s answer to the above question is going to be a bit different but being a therapist myself, and a client within therapy throughout my life and currently; I would like to share my current perspective on what therapy is and why everyone should go.

To me, therapy is a helpful tool to use in order to get to know myself on a deeper, more authentic level.

Within our bodies and minds we all hold the answers to our presenting concerns, but the protective factors and defense mechanisms we’ve built up over the years tend to get in the way of effectively working through our life’s difficulties alone. Therefore, we rely on our coping skills and our loved ones to assist us in times of need. But what happens when your go-to coping skills are no longer working? For a lot of people, it means that you now have to adapt your life and accept the fact that you are now anxious, depressed, alone…fill in the blank — and that’s just the way it is. Fortunately, though this doesn’t have to be the case.

Therapy can be a great way to adapt or change your learned way of life in order to gain a better understanding of your inner workings and what happens when your internal and external worlds collide.

By nature, the process of therapy forces you to be vulnerable. And with vulnerability being the key component to experiencing all emotions (the good, the bad and the ugly) the therapeutic process can assist in the education, understanding, integration and execution of your complex emotions. Therefore, allowing you to take what is learned within the therapeutic hour out into the world and apply it to your life in order to reach our full potential.

In summary, I think that everyone should have access to, and be a client within the therapeutic process sometime throughout their life. It is not something I think people should be in forever, because I do think one of the goals of therapy is teaching clients how to be their own therapists. But I do think everyone should be able to experience the benefits that the unique relationship between client and therapist can have.

Shannon Gonter, a licensed professional clinical counselor (LPCC) in Louisville, Kentucky who works with young adults and specializes in men’s issues

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To me, therapy or counseling is the space in which counselors are able to promote, encourage and support clients in achieving wellness. This space is where clients go to seek out the assistance that they need to improve areas of their lives that contribute to their overall sense of wellness. These areas may include but are not limited to social, cultural, emotional, psychological, spiritual, relational and/or physical.

Therapy is this safe space where I can explore where I am in life, what obstacles I may be facing and what I need to feel whole again. To me, wellness is the experience of wholeness.

Ashley C. Overman-Goldsmith, an LPC and doctoral student at North Carolina State University and owner and lead therapist at Sea Change Therapy in Williamsburg, Virginia. Her current research centers on honoring the lived experiences of terminally ill clients while helping these clients resolve issues that affect their end-of-life experience.

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As a veteran and mental health professional, I often find myself conducting community presentations in order to reduce the stigma against clinical mental health counseling. Often, I find myself having discussions about what therapy is and what it means.

During these conversations, I draw the line between therapy and Therapy. Many find things helpful and calming that they consider “therapeutic,” like gardening, physical exercise, cooking, art, etc. I have clients that say “_____ is my therapy” and that’s great. The meaning in that context is anything that is emotionally soothing or helpful to them.

The other one, though, is Therapy. It is a formal interaction with a licensed mental health professional that is bound by a set of ethical principles, licensure regulations and expectations of professional conduct. I typically use the term clinical mental health counseling, which is more cumbersome but also clearer than just the word “therapy.”

During Therapy, in the clinical sense, a client identifies areas in their life that are not functioning as well as they would like. They then work with a trained professional to develop and work towards goals that will improve that functioning. The professional does not only have training in therapeutic interventions, but they also have training in evidence-based practices that research has proven can help the client resolve their concerns.

Unfortunately, many of the clients I see do not engage in Therapy until the things they have been using to try and manage their problems don’t seem to work. I often describe it this way: if I were a medical doctor, I would be an emergency room doc. The veterans I see come in to my office either right before a crisis, during a crisis, or after a crisis has occurred. Clinical mental health counseling is often seen as a last-ditch effort, a final resort to try before the wheels fall off the wagon.

Instead, I try to encourage clients to consider clinical mental health counseling as a resource to use in order to prevent a crisis, rather than reaching out in response to a crisis. To use Therapy in conjunction with things they consider therapeutic, rather than thinking they are two separate things. For my clients, I have seen this combination help them live the post-military life they both desire and deserve.

Duane France, a U.S. Army noncommissioned officer (retired), combat veteran and LPC who practices in Colorado Springs, Colorado. In addition to his clinical work, he also writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com

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To me, therapy is an opportunity. It seems that with any kind of client, in any type of situation, using any option of modalities, therapy is a gateway to a field of possibilities. I believe one of my greatest gifts to my clients is helping them to facilitate possibilities of thought, feeling and action. With possibilities, clients can see opportunity. Two important words come to mind when I think of opportunity: awareness and empowerment.

Clients come to counseling, voluntarily or involuntarily, but most come with some desire to figure out something. Clients may be looking for specific techniques or just a way to be able to communicate with their partners. They may be court ordered for addictions treatment or just feel like something is not right. Whatever the concern, figuring it out seems to bring insight and peace on some level. Being a licensed professional counselor, certified yoga instructor and an artist has allowed me to provide multiple strategies to foster clients’ inquiry into their presenting concerns. But strategy aside, therapy provides clients opportunities for self-awareness and insight about the world around them.

Additionally, opportunity begets empowerment. One of the key principles of counselor identity is empowerment of our clients to help themselves. I remember working in a community mental health center years ago. Then I was working with children and families who did not have a lot and who had experienced violence, abuse and insecurity in their living situations. I wondered what good could I do in one 60-minute session, and with one meeting per week for each client, especially when I was working in the context of highly distressing situations. Therapy was the act of empowering my clients to find options in how they reflected on themselves and responded to their environments.

With options available, clients can find freedom to choose. Feeling free to make decisions – intentional decisions – is one of the most empowering experiences for anyone. Being able to foster opportunity for my clients means that they have a chance to feel their personal power to make their own choices.

I would say that my primary job as a counselor and counselor educator is being an options-maker or a possibilities-creator! I believe it is in therapy where opportunities are born!

Megan M. Seaman, an LPC, certified yoga instructor and assistant professor in the Counseling and Art Therapy Department at Ursuline College in Pepper Pike, Ohio. She also maintains a private practice in Beachwood, Ohio where she works with children, youth and families using creative arts healing and yoga therapy strategies.

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To me, therapy is providing an open space for people to have the opportunity to discuss life events or problems that are impacting their daily lives. This is a place where someone feels heard. Our lives are often so busy that we don’t listen.

Counseling provides this safe place for someone to “unpack” life problems and look at them with someone who is truly listening and is available for unbiased support. Therapy offers the opportunity for people to discuss and explore ways to improve their lives and find resources to enhance their quality of life. Thus, they find the strength to manage difficult life events such as trauma, illness and adjustment to disability.

Therapy is also the passionate pursuit of learning and effectively using practice-proven and evidence-based practices to help with the healing process. But, it also requires a counselor to have the courage to question, redirect, and, yes, confront a client to keep them on the path to wellness and wholeness.

This is hard work! But it is an honor to be trusted by someone who doesn’t know us to listen, care and support them during their most vulnerable times.

Judy A. Schmidt, a certified rehabilitation counselor (CRC), licensed professional counselor associate (LPCA) and clinical assistant professor in the Clinical Rehabilitation and Mental Health Counseling program in the Department of Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill. She is the rehabilitation counselor for the acute inpatient rehabilitation unit for UNC Hospital in Chapel Hill.

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To me, therapy is a communion of two souls who make an agreement to walk alongside each other for a part of this journey. Therapy calls us to bear witness to another person’s healing process by helping them to come back home to their true and authentic self. It reminds us of our wholeness and asks us to remove any barriers that prevent us from seeing this wholeness.

Therapy reminds us that we cannot have the shadow without the light and that the shadow only exists because of the light. It is about quieting the ego and the mind in order to get us out of our heads and into our hearts and bodies.

Therapy involves being truly seen and heard by another person to help us remember that we are not alone on this journey. It is about accepting someone for who they are (battle scars and all) while also seeing their infinite potential.

Jessica Smith, an LPC, licensed addiction counselor, yoga teacher and owner of Radiance Counseling in Denver, Colorado

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Bethany Bray is a senior writer for Counseling Today. Contact her at bbray@counseling.org

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

A script for socialization to the cognitive model

By Brandon S. Ballantyne May 14, 2019

Cognitive behavior therapy (CBT) is an evidence-based treatment approach that has statistically been shown to be effective in addressing a variety of mood disorders and psychological problems. It is my belief that a key component to successful cognitive behavioral treatment is counselor-to-client socialization of theory and concept.

It is essential that clients become socialized to the cognitive model — understanding the rationale behind CBT’s effectiveness — to gain maximum benefit. For that reason, I have developed a script that counselors can use with the clients they serve. This script aims to provide a blueprint for live, in-session socialization to the cognitive model and provides a platform to transition into routine practice of cognitive behavioral technique in future sessions.

Script introduction

If I were to ask you to think of a palm tree, what do you think of? You probably just imagined a palm tree. If I were to ask you to think of your very first car, what do you think of? You probably just imagined yourself either in or next to that memorable first automobile. If I were to ask you to think of your favorite food, what do you think of? You probably just imagined your meal of choice.

Now, if I were to ask you to feel anxious, what do you have to do? Most people say they need to imagine a stressful scenario to feel the emotion of anxiety. The point is that we can instantaneously produce any thought. However, when it comes to producing an emotional state, we first need to think of something in order to feel something.

The formation of emotions is a biological process, meaning that it is impossible to shut off or terminate from human experience unless we suffer serious medical injury that leads to such complications. With that being said, there is a specific sequence of internal and external events that not only create, but contribute to, the emotional experiences of you, me and everyone else with whom we share this wonderful planet.

Situation

For an emotion to be formed, one must first encounter a situation. A situation is anything that an individual becomes aware of. It can be an external event such as a person, place, thing or activity. It can also be an internal event such as a particular thought or emotion.

Let’s say that tomorrow, I wake up, get in my car and start my drive into work. I encounter a traffic jam, which I anticipate might make me late to my destination. As I approach, I become aware of the traffic jam itself. Both the awareness of the traffic jam and the traffic jam itself become the situation at hand.

Thought

Our brain is like a thought warehouse. It has a job of producing thoughts throughout the day — every second, every minute, every hour.

What is a thought? A thought is a sentence that our brain produces about the situation at hand. Thoughts have sentence structure. Each thought has punctuation. It can also take the form of an image or movie that we experience in our mind.

On some occasions, we verbalize our thoughts out loud. Sometimes they stay silent. Regardless, they affect how we feel. If I am driving to work and become aware of the traffic jam, my brain might produce the thought of, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

The first thoughts that our brain produces about a situation at hand are automatic. We don’t really have control over them. But as I mentioned earlier, these thoughts affect how we feel, so they are important to accept and to understand.

Emotion

Once our brain produces a thought about a situation at hand, there is the onset of some kind of emotional experience. How is an emotion different from a thought? Emotions can be categorized into mad, sad, glad and fearful. Any emotion that we have at any given time will likely fit into one of these categories of primary emotions.

There is also a subtle category that some identify as “neutral emotions.” However, we are rarely taught about what neutral emotions are. Throughout our life experiences, we are given the message that there must be a way to feel and that emotions need to be either pleasant or unpleasant. Therefore, if we aren’t particularly happy, sad, fearful or mad, we tend to say that we are feeling “nothing.”

Emotions are a biological process. And because our thoughts are automatic, we never really have an absence of emotions. So, when we are feeling “nothing,” we are actually feeling “neutral.” Descriptors such as “content” and “OK” best describe a neutral emotional state.

Now, let’s refer back to the traffic jam scenario. While sitting in the traffic jam, I am having the thought, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

Because of this thought, I am most likely to be feeling anxious. Anxiety is most closely related to the primary emotion of fear. Some emotions occur parallel to physical symptoms as well. For example, if I am sitting in my car feeling anxious from the thought about being late to work, I may also notice that my hands have started to sweat. Physical symptoms help us to identify and label emotions.

So, it is important to pay attention to your patterns in your physical symptoms as you experience emotional states. In general, emotions give us information about the situation at hand. However, it is then our job to examine that information accordingly.

Behavior

Our behaviors are influenced by the emotions we experience. Behaviors can usually be observed by others. Based on the specific characteristics of the behaviors — and the specific characteristics of the reactions that the behaviors provoke in others — these behaviors can help us to get closer to our goals, push us further from our goals, or neutralize the pursuit of our goals.

What does it mean to neutralize the pursuit of our goals? Well, some behaviors neither get us closer to nor push us further from our goals. These behaviors can be referred to as “neutralizing behaviors.”

In the example of sitting in the traffic jam and feeling anxious, I may react to the intense anxiety by engaging in behaviors such as beeping my horn and yelling at other drivers.

Result

Results can be defined as a set of benefits or consequences that are produced by one particular behavior or set of behaviors. Results can be desirable, undesirable or neutral.

Desirable results are outcomes that take us closer to our goals. Undesirable results are outcomes that push us further from our goals. Neutral results neither take us closer to our goals nor push us further away.

In the traffic jam example, the behavior indicated was beeping the horn and yelling at other drivers. We can anticipate potential results that those behaviors may produce. As a reminder, the goal in that scenario is to get to work on time, or at least not too late, and safely.

One possible result of beeping my horn and yelling at other drivers is that other drivers may begin beeping their horns and yelling at me. This additional conflict may cause my anxiety to intensify further. At the same time, everyone beeping their horns and yelling at each other will not change the fact that I am sitting in the traffic jam itself. Therefore, this outcome can be categorized as an undesirable result.

Wrapping it up

The goal of this type of cognitive behavioral style work is to identify where in the process above an individual may have personal control or personal choice of changing the problematic patterns or tendencies. By examining the above scenario in that way, individuals will be able to conceptualize aspects of personal choice and change that can help them reduce intense emotional distress, engage in healthier behaviors, and achieve more desirable results — first in the above scenario and then with the real-life stressors that have brought them into treatment.

Use the following reflection questions to get started with application of this skill:

1) If you were stuck in a traffic jam similar to the one described above, what would be going through your mind? What are some of the automatic thoughts you would be having?

2) What kinds of emotions would your automatic thoughts produce? Would you be noticing any symptoms of those emotions in your body?

3) What type of automatic behaviors might you engage in based on the influence of those emotions or physical symptoms?

4) What type of outcomes or results would those behaviors likely produce? Would those results be desirable, undesirable or neutral based on your goal of getting to work on time, or not too late, and safely?

5) Is there anything else you might be able to say to yourself in the scenario about the traffic jam that would produce less intense distress? If so, what are those thoughts? Remember, thoughts come in the form of sentences or images.

6) If you were able to insert those new thoughts the next time you experience a traffic jam, what types of emotions would those thoughts likely produce? If they do not produce less intense distress or new emotions comprehensively, try identifying new thoughts (sentences) until you find one or two that either reduce the distress or produce new desirable emotions.

7) With less intense distress or new desirable emotions, what are the new behaviors that likely would be produced as a result?

8) Given the likelihood of those new behaviors, what would happen next? In other words, what would be the results of those new behaviors? Would those results be desirable, undesirable or neutral based on the goal of getting to work on time, or not too late, and safely? If those results are desirable or neutral, then you have successfully completed examination of this scenario. If the results are undesirable, repeat steps 1 through 8 until you are left with desirable or neutral results. If a neutral result does not make the situation worse, then it is desirable in itself.

9) What are some situations in your life that have caused stress?

10) What were the automatic thoughts running through your mind at the time?

11) Given those life situations, what were the undesirable results that were occurring?

12) Given those life situations, what were the behaviors that were contributing to those undesirable results?

13) Looking back, could you have said anything different to yourself in those moments to reduce the level of stress? If so, what would those coping thoughts be?

14) Given those life situations, what are examples of healthier behaviors that you want to be able to engage in?

15) Given those life situations, what emotions would be needed to make those healthier behaviors easier to achieve?

16) Given those life situations, what results would you want to be able to achieve, experience or receive?

17) With those desired results in mind, what can you say to yourself about those life situations that might help to produce healthier emotions and healthier behaviors?

18) Copy down those thoughts. Put them on an index card. This will serve as your coping cue to take with you. It will be a reminder that although we may not be able to fix a stressor at hand, we do have the opportunity to access alternative thoughts. It is those alternative thoughts that kickstart the process of reduced distress, healthier behaviors, and the satisfying experience of more desirable results. Thus, we are creating an opportunity for achievement as we assist ourselves in getting closer to our goals, even if certain stressors stay the same. With consistent practice, we teach our brains that we control our thoughts, emotions and behaviors. We give power to ourselves in knowing that we do not need situations to change in order to feel better and do better.

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Brandon S. Ballantyne has been practicing clinical counseling for 12 years. He is a licensed professional counselor and national certified counselor who specializes in the treatment of anxiety and depression. He currently practices at a variety of different agencies in eastern Pennsylvania. Find him on the web at https://thriveworks.com/bethlehem-counseling/our-counselors/, and contact him at brandon.ballantyne@childfamilyfirst.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.