Contents

Cover

Half Title page

Title page

Copyright page

Dedication

Preface

Acknowledgments

Part 1: Client Questions in a Broad Context

INTRODUCTION TO PART 1

WHY DO CLIENTS’ QUESTIONS CAUSE APPREHENSION?

WHAT DO THE DIFFERENT THEORIES ADVISE?

REMEMBER, IT’S NOT ABOUT YOU

GUIDELINES FOR ANSWERING QUESTIONS

STYLE AND LANGUAGE CONSIDERATIONS

FURTHER THOUGHTS

Part 2: Client Questions and Responses by Topic

INTRODUCTION TO PART 2

Chapter 1: The Early Sessions

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 2: Experience

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 3: Therapeutic Process

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 4: Expectations About Change

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 5: Techniques

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 6: Professional Role

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 7: Money

QUESTIONS

RESPONSES

MONEY QUESTIONS UNRELATED TO THERAPY

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 8: Confidentiality

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 9: Boundaries

QUESTIONS

RESPONSES

BOUNDARY SLIPS

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 10: Personal Questions

QUESTIONS

RESPONSES

QUESTIONS ABOUT THE THERAPY RELATIONSHIP

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 11: Sexuality

QUESTIONS

RESPONSES

QUESTIONS THAT INVOLVE THE THERAPIST

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 12: Religion and Spirituality

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 13: Prejudice

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 14: Stigma

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 15: Physical Appearance

QUESTIONS ABOUT THE THERAPIST

RESPONSES

QUESTIONS ABOUT THE THERAPEUTIC ENVIRONMENT

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 16: Dreams

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 17: Therapists’ Reactions

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 18: Individual and Cultural Differences

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 19: Involving Others

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 20: Out of the Office

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 21: Keeping in Touch

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 22: Life Events

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 23: Ending Therapy

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Concluding Thoughts

References

Index

About the Authors

What Do I Say?

Copyright © 2011 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Published simultaneously in Canada.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008.

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Library of Congress Cataloging-in-Publication Data:

Edelstein, Linda N.
What do I say? : the therapist’s guide to answering client questions / Linda N. Edelstein, Charles
A. Waehler.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-470-56175-1 (pbk.); 978-1-118-06146-6 (ePDF); 978-1-118-06147-3 (eMobi); 978-1-118-06148-0 (ePub)
1. Counselor and client. 2. Psychotherapist and patient. I. Waehler, Charles A. II. Title.
BF636.6.E34 2011
158′.3—dc22                   2010051401

To my clients, past and present, because I admire their courage, honesty, hope, and hard work. —L.N.E.

To my students, with thanks for all that we have learned together, and for the places we will go. —C.A.W.

Preface

For many years we have consulted with each other about our work as psychotherapists, teachers, and supervisors. We have always agreed on how much we enjoy working with new professionals and having a hand in the next generation of clinical work. Last year, we discussed writing down answers to clients’ questions to arm therapists because we knew that questions and answers is a topic that is rarely written about, despite therapists’ anxious concerns. When we seriously got down to writing this book, we realized that rather than arm practitioners as if they were going into battle, we wanted to empower therapists to view questions and responses the same way they see other collaborative pieces of clinical work.

Most books about the psychotherapy process devote a couple of paragraphs to admitting that clients ask questions and that these questions probably have significant meaning. These comments also suggest that we ought to use clients’ questions effectively in the growth and healing process. It is rare, however, to find a full discussion of questions. Specific suggestions for answers are even more uncommon. Instead, we have seen that serious conversations about how to respond to questions are left to supervision or thrown into courses as a byproduct of other work, if at all. But we knew from our own clinical experiences, from teaching, and from consulting to other clinicians that clients ask a lot of questions, often very good questions. Unfortunately, therapists can feel flummoxed when this happens because they haven’t had opportunities to sort out their concerns, beliefs, and practices.

The more we consulted with other therapists and with students about the idea of a book about clients’ questions and therapists’ responses, the more we uncovered all kinds of previously unspoken feelings, mostly discomfort and apprehension. Concerns such as “I don’t want to lead my client down the wrong path,” “I won’t know the answer,” “I’ll reveal too much,” “I’ll look stupid,” “I’ll feel stupid,” and “I’ll say the wrong thing” came from both novice and experienced therapists. We began to think that being asked questions by clients conjures up images of the horrible third-grade teacher who put you on the spot, or the mean kids who snickered, or the parent who quizzed you during dinner. Questions then begin to feel like an inquisition, and responding becomes a competitive win-or-lose game. But therapy isn’t a test; it’s not even a quiz—it is a relationship. For better or worse, you and your client are tethered together, and if either of you fail, both of you fail.

We know that, as mental health service providers, your effectiveness is related to how comfortable and competent you feel in the room with your clients. If you are anxious, distracted, or fumbling around for what to say, your ability to be attentive to your clients—to be a healthy and professional person in the room—will be compromised. At these confusing times, you wish that you could have a quick consultation with a supervisor or colleague. Later, in the car or in the shower, you come up with an ideal response and wish you had thought of it earlier. We wanted to write a book that helps mental health professionals feel confident during anxiety-provoking situations with their clients.

This book is set up so that both beginning students and more experienced practitioners can think about their interactions with clients’ questions. We want this to be the book that therapists wished they had read before they sat across from a client and felt overwhelmed by inadequacy. At one time or another, every therapist has wondered unhappily, “Why didn’t my supervisors or professors prepare me for this?” We hope to serve readers in ways similar to the ideal supervisor, who helps formulate the words that express what the therapist wanted to say. Lonnie, a Smith College MSW graduate, called this book, “a supervisor in my backpack.”

We conceptualized this book as practical and friendly, and we have tried to write it in that spirit. We imagined that we were sitting around with some of our favorite graduate students and colleagues and having fun with the ideas. Linda actually had dinner parties with her team of graduate students where they shared their developing thoughts. Charlie talked about these issues with his colleagues in a group private practice and reviewed them with his advanced practicum classes.

We also surveyed graduate students and asked them, “What client questions make you apprehensive?” We received about 70 generous replies with hundreds of questions that would give even the most seasoned professionals reason to pause and reflect. We used the questions generated by the surveys, added ones from our own combined halfcentury of practice, and went to experienced colleagues for even more questions. We gathered an excellent, super-sized collection that we grouped into logical categories. We could have simply considered ways to respond to client questions that would get you past the awkward moments, but to do so would be similar to telling you to close your eyes during the scary part of a movie. Instead, we have devoted this book to thinking about ways to use client questions to enhance therapy.

First, we address ways to think about client questions and potential therapist responses in terms of general constructive strategies. To this end, we talk about some big-picture considerations as well as make focused observations about language and word use.

Second, knowing that clinicians are frequently faced with questions on specific topics, we have organized the questions and responses into 23 of the most commonly asked subject areas. We move through these 23 topics in an organized manner, asking numerous questions, examining underlying issues, proposing possible responses, and ending with further thoughts and references for additional reading. We present our rationale and thinking behind the responses. Some questions and their answers are challenging because the context is complicated, whereas others are more straightforward. These are all meant as jumping-off points for our readers. The ideas are useful to consider ahead of time so that you are more at ease during sessions. We have written in a conversational tone and illustrated our ideas with examples from our own lives and work, and from the experiences of our guest clinicians, both seasoned and brand new. In reading the experiences of others and writing down our own, we relearned that many experiences are common and, although we need to treat our work seriously, we are better off when we take ourselves lightly.

In reading, we expect that you will skip around to topics that challenge, confound, or confront you. If you do jump around from topic to topic, please recognize that certain themes could easily be considered in all chapters (e.g., ethics), but they are not repeated in every applicable chapter. Several topics, like diversity and boundaries, have specific chapters of their own and also are germane to all other areas.

Although we want to inform, even prod, you by the considerations we have brought into this text, we don’t want you to use the proposed responses in a cut-and-paste fashion with your clients. To do so would take away your individuality and the special quality that emerges from forging unique relationships with clients. Instead, we trust that you will modify, individualize, and personalize your responses. Our language can be easily incorporated into a therapy conversation, but we know that good therapy is not done by following a script. Although thinking ahead can be helpful, therapy evolves from the interactions in session. You respond in the moment to a client’s very personal, idiosyncratic statements, and no two sessions are ever alike. As you personalize the elements in the book, you will become increasingly spontaneous and confident.

The material in this book comes from a variety of theoretical orientations. Some theories emphasize different aspects of client treatment, but many elements, known as common factors in the literature, cut across different orientations. These elements account for a great deal of the successful change we all work toward with clients. We have used therapist responses that fit into a common-factors approach. You may notice that two core ideas related to psychotherapeutic work permeate the book:

With these two ideas in mind, you will see that we use some psychodynamic terms because we were both trained and continue to be informed, particularly at the conceptual level, by theories that appreciate the power of our clients’ internal dynamics and irrational conflicts. Linda considers herself a feminist therapist, and Charlie describes himself as an integrative, multitheoretical therapist. We both value clients’ cognitive, affective, and behavioral learning. We appreciate their contextual, cultural, and systemic concerns, as well as individual differences, and have integrated aspects of the major theoretical orientations into our work and into our attempts to formulate consistent, well-considered responses.

We are also informed by the Presidential Task Force on Evidence-Based Practice in the American Psychological Association (2006), which created a policy statement that says, in part, “Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 284). This sentence reflects the three components that help direct successful therapeutic interventions: empirical evidence (broadly defined), clinical expertise, and client characteristics.

With regard to empirical evidence, we have reviewed the literature and, not surprisingly, little experimental data exist that have examined the dialogue of questions and responses. We have enjoyed and absorbed the theoretical discussions when we could find them, reviewed the research and and practice recommendations, and then attempted to present the material in ways that mirror the actual activity and flow of the therapeutic session or supervisory discussions. At the end of each chapter, we have included sources that might be interesting to our readers.

Clinical expertise, our own and others’, heavily guided our responses to questions. We tried hard to capture everyday examples of queries and, more importantly, to examine what clients reveal with their questions. In doing so, we hope to expand your therapeutic understanding of material that can help clients change.

With regard to client characteristics, in specific chapters you will see some references to individual differences such as race, religion, sexual orientation, age, socioeconomic status, privilege, or ability, but more often, you will read many comments urging you to appreciate each client. We also know that our readers are individuals with as much variety as our clients. In this way, each therapeutic relationship reminds us that people connect despite their perceived differences. In Chapter 18, Individual and Cultural Differences, we have included many of the specific questions that come up with regard to individual differences.

You will notice that we chose to alternate our description of therapists and clients as male or female rather than addressing them in the text as him/her or he/she. We certainly recognize that clients and therapists can be either gender, but including he/she or him/her all the time is awkward and changes your experience as a reader. We hope this does not inadvertently promote any gender stereotypes. Also, we have included many examples from clients and clinicians. Most clinicians are identified and clients’ identities are changed (although we have permission to use their stories) to ensure confidentiality.

If you want to get in touch with us for questions or comments, Linda is available through email, l.edelstein@sbcglobal.net or through her blog, www.lifeaintforsissies.com, where you can join the conversation. Charlie can be reached at cwaehler@uakron.edu.

Linda N. Edelstein, Evanston, IL
Charlie A. Waehler, Akron, OH

Acknowledgments

Linda

I never wanted to write a book about therapy, unless it was a mystery novel, so when Charlie and I came up with this idea about questions and answers, it was an unexpected gift. During the writing, I’ve had the opportunity to think back over the years and reflect on many significant moments in treatment. I’ve also gotten clearer about some ideas that matter to me. I’ve been a therapist for a long time, and this book became the culmination of teaching, clinical work, reading, conversations, and personal thought. Mostly, it has been a lot of fun.

Even with Charlie, a co-author who envisioned the book just like I did, writing is a notoriously solitary process, but I have received a lot of help. I want to thank my dynamic graduate student team of Damon Krohn, M.A.; Jessica Bell, M.A.; Elizabeth Marklein, M.A.; Dina Zweibel; and Greg Rizzolo. The team independently researched chapters, generated original ideas, and added information and liveliness that would have been missing otherwise. In the very early stages, Luna Sung worked on preliminary versions of the chapters about prejudice and stigma.

My writing group is made up of loyal friends who are also esteemed colleagues, Margit Kir-Stimon, Ph.D.; Melissa Perrin, Psy.D.; and, for awhile, Joan Liataud, Psy.D., all of whom remained on call for reading, editing, and complaining. I want to thank Nancy Newton, Ph.D., my comrade on many projects over the years, who has generously and endlessly been able to take my thinking to more creative places and pull me out of mental mud. Additional thanks go to my office partner, Patty Shafer, Ph.D., who was willing to talk with me about clinical work and theory; Keira Dubowsky, who helped with the cartoons (that never made it to the final version of the book) and other creative ideas; and Jennifer Dubowsky, M.S.O.M., who very patiently listened to the process of writing and encouraged everything, including the website and blog so that we can continue the dialogue.

Also, special thanks to friends Anita Adams, M.B.A.; Ken Adams, J.D.; Karen Drill, M.A.; Janna Dutton, J.D.; Eve Epstein, J.D.; and Hedda Leonard, who were all very kind to me, made themselves endlessly available to discuss this project, and who are probably as happy as we are that the book is done.

Charlie

Those of you who know me well know that I am a collector. I like to cling to valuable thoughts, ideas, and wisdom, as well as relationships, connections, and all sorts of experiences. This book has provided a wonderful opportunity to sort through many different ideas, combining and reworking them with novel notions to give them new life and energy: that has been a joy for me. Most joyful among these has been the opportunity to create new connections with students who provided invaluable assistance in identifying, exploring, clarifying, and energizing ideas that have enriched this material. Chief among these people has been Sam Gregus, whose blend of curiosity, wisdom, hard work, and good cheer kept advancing the work. Other students who assisted in a variety of activities have included Zack Bruback, M.A.; Sara Carnicom; Jill Hendrickson, Ph.D.; Jennifer McDonnell; Lindsay Newton; and Jennifer Underwood. Colleagues who have also been of assistance have included Mark J. Hilsenroth, Ph.D.; and James L. Werth, Ph.D.

I also want to acknowledge the support and understanding I have received from my immediate and extended family as I have taken private time to work on this material. I hope that all the delayed gratification necessitated by the work will prove worthwhile. I also appreciate the support and understanding from my professional colleagues and graduate students for the time and energy that has gone into this project. Thanks, too, to Linda, who has again proven to be a great fellow traveler.

Linda and Charlie

Early in the process, we were guided by Margaret Zusky from John Wiley & Sons, who led us to our editor “in perpetuity” Rachel Livsey. We have been very lucky to work with Rachel, who commented on all aspects of the project with laser-like accuracy. Also, thanks go to senior production editor, Kim Nir. To gather client questions, we surveyed graduate students in Ohio, California, Illinois, and Virginia. They filled out surveys and provided us with hundreds of examples of questions that make them anxious. We used many of them. This also helped us to realize that we wanted to gather more clinical examples than those we could cull from our own careers, so we asked other students and colleagues to share their experiences as guest clinicians and they graciously consented. Their contributions have made the book richer than it would have been otherwise. We are grateful to the people who allowed us to use both their stories and their names: Jeremy Bloomfield, Psy.D.; Margit Kir-Stimon, Ph.D.; Carol Kerr, Ph.D.; Damon Krohn, M.A.; Elizabeth Marklein, M.A.; Mary Miller Lewis, Ph.D.; Nancy Newton, Ph.D.; Melissa Perrin, Psy.D.; Hinda Pozner; Abbey Prujan, M.A.; Lee Rodin, M.S.W.; Tammi Vache-Haase, Ph.D.; and Naomi Woods.

Particular thanks to Carol Kerr, Ph.D., who advocated for and wrote most of the chapter on Individual Differences. Thanks also to Mark Epstein, J.D., a mental health lawyer who reviewed the chapter on Confidentiality, and Meghan Roelke, Psy.D., who distributed surveys to her class at The Chicago School. At the completion of the writing, before publication, we had the good fortune to be reviewed by six anonymous clinicians and educators who read carefully, commented artfully, and brought some new ideas to the project.

To our clients from whom we have learned much and who have allowed us to use their questions and experiences, thank you. We hope we have been faithful to the spirit of our collaboration.