A colleague and I were recently discussing a question that seems to come up often in behavioral and cognitive therapies. It can be used with clients at any stage of therapy, and it’s an inquiry that few people in our daily lives ever really ask, meaning that it holds a certain level of power and punch within a clinical setting.
So, how has that been working out for you?
In therapy (as in life), we usually know the answer to this question before we ask it. Our clients have come to us for a reason, the reason usually being that they want things to be different. But how often have you or I or any of us wanted to put the work in for things to go differently? Sometimes, occasionally, rarely.
As human beings, we are essentially optimized for stasis. We figure out something that gives us an adequate amount of short-term rewards with not too many long-term punishments (or at least, punishments that we won’t have to experience for such a long time that they are barely a shadow on the distant horizon), and we stick with whatever it is. Even with evidence to the contrary. Even with our family, friends, colleagues (and our own minds!) telling us it’s a bad idea.
You know that doughnut is bad for your cholesterol.
I should be getting out and socializing more, but I’m just so tired after work.
You are going to have to learn how to control your anger one of these days.
The pull of inertia is strong. Which means that even among clients who come into therapy looking for concrete changes in how they behave, how they feel, or how they interact with their feelings, we are likely to hear some ambivalence.
There are entire therapies devoted to this very topic (check out resources on Motivational Interviewing if you haven’t already). But without delving into a whole treatment, the question above can offer a means of engaging our clients on the issue of change vs. inertia effectively. However, as with most elements of behavioral and cognitive therapies, the question itself is not as important as how you ask it.
The critical thing is that the question has to be genuine. It’s very, very easy to have a question like this edge into sarcasm, particularly if you already have a sense of how something is working (or more likely, not working) for your client. For example, let’s say a client has come to you to work on longstanding symptoms of depression. He might have a job, but spends much of his extracurricular time in bed, avoiding anyone or anything. And while this choice feels better to him in the moment than getting up and interacting with the world, his experience is one of deep loneliness, shame, and regret. He wants to be engaged in his life, wants to have friends, wants to feel that he is really living rather than simply existing.
Being the good cognitive behavioral therapist that you are, you might incorporate some behavioral activation into your work together, encouraging the client to try some new activities, to spend just a few minutes each day out of bed and engaged in his life. Some clients with persistent depression (it’s rare, but it could happen) might say, “Of course! Wow, thank you so much for this idea! I will start talking to more people and participating in more activities as soon as I leave the session.” More common (much, much, much more common) is some variation of the following: “I don’t know. I feel so tired and exhausted at the end of the day. All I want to do is sleep. And on the weekends I need to catch up on my rest or I’ll feel even worse next week. And when I’m with people, I can’t have fun anyway, so there’s really no point. Even when something really great is happening, it’s like the part of me that wants to enjoy it is trapped behind a thick, steel door that won’t let me feel any differently. I’d rather just be in bed.”
This is where the question comes in. First, start with validation. Validate the experience of not wanting to do anything, of not feeling enjoyment even when the client does engage in something. This experience only makes sense for someone who is depressed, and we can probably all think of times in our own lives when we have wanted to spend some time dozing by ourselves, when the world seemed like too much to handle and retreat was significantly more appealing. We want to truly validate the client from that place, the place of visceral understanding (which we all have – we’re human after all) of what it’s like to want to escape the world and especially the people in it. As always, tone is important. The best approach is to actually connect with this experience and this feeling in your own life and convey that sense of lived understanding through whatever tone is most authentic to you. I usually say something like, “Of course. Of course you don’t want to get out of bed. Of course you don’t want to interact with others. You feel absolutely terrible almost all of the time, and being around other people only reminds you of what you don’t seem to be able to do right now, which is feel happy or connected or joyful.” My tone usually takes on a feeling of passion in a statement like this, mainly because what feels most authentic for me is to try to connect to the power that my client’s sadness and isolation holds over his or her life. However, your tone (and certainly your word choice) should be specific to whatever is most authentic to you. The important thing is to start by just validating. It’s easy to jump into problem solving or convincing, but the validation is key. It lets the client know that you aren’t just sweeping their objections away (which is inherently invalidating). Instead, you’re genuinely trying to understand what makes this so difficult for them at this moment in their lives. Usually, clients will respond to validation by either reiterating some of the points they made previously about their difficulty in engaging in more activity or they will in some way acknowledge the emotional component of this struggle. “Yes, it’s been really difficult for me to do anything at all” or “Yeah, it sucks. All I want to do is be by myself and not have to see anyone.”
Now, you actually ask the question. “So, how has that been working out for you?” or “So, how has that worked for you?” What is critical here is that you ask this question in such a way that communicates you genuinely want to know the answer. This is more than just highlighting the discrepancy between what they’re saying right now about the difficulties of change and what they said in the past about how much they want to make these changes. This is a question that needs to come from a place of curiosity. Because there are ways in which this IS working for the client. Otherwise, he or she would not be engaging in this behavior. In the case of our example client, he is getting something real from laying in bed all of the time, and we need to be thinking of what it is (and including this information in our conceptualization to guide our choice of intervention). Some guesses: relief from the constant reminder that he is cut off from others and from most positive emotions, a bit of peace and quiet, a chance to forget that his life is not going the way he wants it to, connection with the world through passive means (TV, news, scrolling through Facebook or Twitter or Instagram), physical comfort associated with lying in a comfortable bed. Whatever he’s getting (and it may be more than one of these things or something else entirely), it’s important that we understand what it is while also helping him place this reward in the context of the life he wants for himself.
When asking this question, I have found (and you may certainly find something different, depending on your own style and presence in the therapy room) that a gentle but straightforward tone works best. Veering into sarcasm or stridency is not effective. I have also found that it is helpful to make eye contact as you ask the question. You want to connect with the client in this moment, cutting through any urges to defend themselves with more reason-giving or avoid supplying the true answer, and holding steady, open eye contact is usually an effective means of doing that.
The mood in the room usually shifts in this moment. If you’ve asked the question in a gentle way that seeks a true answer, there is a sense of honesty and forthrightness that is often different from what came before. We’re no longer talking about what’s easy; we’re talking about what’s true. Yes, it’s easy to lay in bed all day. But what’s true is that our client is deeply lonely. Usually, this question can help elicit that truth.
Some clients will laugh a bit. Others might stare at you for a moment. As I mentioned before, this is not a question that most people in our lives ask with the expectation that they will receive a genuine answer. It may be asked sarcastically, but most often our loved ones don’t ask any question at all. Instead, they tell us directly the many reasons that our choices have not been leading us down the right road in their opinion. This pulls for us to defend ourselves, which is why that’s usually the first response we get in the therapy room as well – a list of reasons why making a change is impossible. But this question can open up something different. We all have reasons why we don’t do more of some things and less of others. Asking a client how well those reasons are working for them helps to cut through the reactionary responses and can lead you toward something real. Clients will usually give an honest answer (sometimes only after I clarify that yes, I am seriously asking how it’s working, and yes, I’m assuming something about it does work, at least in the short-term). This can give you the space to ask them to try something new.
As always, buttressing the request for new behavior with validation is helpful. In this moment, I usually attempt to preserve the quieter, more honest mood that we initiated a few moments earlier by keeping my voice relatively low, and my tone warm but straightforward. “So in many ways, this behavior is not working for you. Laying in bed all day feels safe in the moment and keeps you from all of the reminders of what you don’t have right now, and at the same time, you know that you want something different for your life. You want to be involved and engaged with people who are important to you. You want to be finding enjoyment and meaning in the process of living, rather than just existing.” Usually this is a bit of an extension from what the client has said. If I ask our example client how laying in bed all day is working, and he tells me that it’s not really, that he’d like to have more friends, then I make a statement like the above in order to connect him to something more powerful and meaningful than someone to occasionally eat dinner with. I’m attempting to connect him to a fuller and richer picture of his life, since we know that’s probably closer to what he actually wants (it’s what we all want).
After a statement like this, I will then transition to actually asking for some new behavior (in this case, a bit of behavioral activation). However, I think this is a moment where you usually have enough room to have the client generate ideas for what to do next. Hopefully, they are feeling connected to what they truly want and slightly less attached to their many reasons for not engaging in challenging, stressful, not-immediately-rewarding behavior. So I often ask them something like, “So what would you like to do this week?” or “So what would you like to do next?” You can get more specific if needed (“What would be one step you could take this week to get closer to that goal of being more connected to others?”), but an open-ended question will at least start you down the road to making a specific plan, while still allowing the client to feel connected to this larger sense of what’s important to him and what has not been working about his current way of doing things. If things have gone well, you can often take a backseat here, and let the client generate some ideas with just a bit of shaping and guidance from you. Depending on the client, you might also occasionally intersperse some additional validation about how this might be challenging (it’s a whole new way of doing things, after all), and that you can see how important taking these challenging steps is to the client in terms of helping him get closer to the life he imagines. The theme of this intervention really is accurate, genuine validation interspersed honest discussion to hopefully open up a bit more space in which the client can experience some willingness to try something new.
I’ve included an example transcript of how this sort of conversation might go in the space below, and as always I’d love to hear your thoughts/reactions/questions in the comments, particularly if you’ve been able to give this approach a try!
Example Transcript: Asking the Question
Therapist: So I’ve been thinking that it might be helpful to work on planning some activities for this week. We spoke before about how doing more fun and enjoyable things can help with feeling down and can also help get you more engaged with things that you like. So what kinds of things would you like to do this week?
Client: I don’t know. I feel so tired and exhausted at the end of the day. All I want to do is sleep. And on the weekends I need to catch up on my rest or I’ll feel even worse next week. And when I’m with people, I can’t have fun anyway, so there’s really no point. Even when something really great is happening, it’s like the part of me that wants to enjoy it is trapped behind a thick, steel door that won’t let me feel any differently. I’d rather just be in bed.
Therapist: Of course. Of course you don’t want to get out of bed. Of course you don’t want to interact with others. You feel absolutely terrible almost all of the time, and being around other people only reminds you of what you don’t seem to be able to do right now, which is feel happy or connected or joyful.
[Tailor your validation to what works for you and fits with your style. For me, this would be said with some level of passion, in an attempt to connect with the seriousness with which the client views his barriers to more activation.]
Client: Yeah, it sucks. All I want to do is be by myself and not have to see anyone.
Therapist [gentle, straightforward, looking the client in the eye]: And how has that been working for you?
Client: [A few seconds of silence.] What?
Therapist: I’m genuinely asking. How has spending all of your time alone been working out for you?
[Really hold the eye contact here and remember to ask the question in a fairly neutral, straightforward way. You are creating space in this moment for the mood to shift, to cut through the reasons and connect over the pain of this aspect of his life. Slowing down and allowing space for silence can also be positive as you ask this question and process the client’s response.]
Client: It’s not. I hate it. It’s not what I want.
[This is probably the point where you’re thinking, it’s never that easy in real life. That’s true – every client is not immediately going to highlight all of the problems with their current approach. If the client doesn’t go right to a genuine answer of how this hasn’t been working, then I would ask the question again in a slightly different way (“So you spend almost all of your time alone. I’m wondering – how has that been going?”). I would conceptualize any sort of reason-giving at this point as a form of avoidance, which you don’t want to reinforce or get distracted by, so you want to stick to your position by continuing to ask the client to confront the truth. If the client continues to give reasons, then you can also highlight that there are ways in which this behavior IS working – it’s giving the client something. If the client agrees, then some extending can be helpful. “There are certainly reasons that laying in bed all of the time feels more enjoyable than getting up and going out. So what do we have to talk about?” Extending means that you’re taking the client’s comments out to their logical conclusion (in this case, that being in bed is a positive thing and he doesn’t need or want to make any changes). Clients will often come back with the ways in which they do actually want to change, which you can then validate before helping them to establish how they would go about making concrete changes.]
Therapist: So in many ways, this behavior is not working for you. Laying in bed all day feels safe in the moment and keeps you from all of the reminders of what you don’t have right now [validating how hard this is!], and at the same time, you know that you want something different for your life. You want to be involved and engaged with people who are important to you. You want to be finding enjoyment and meaning in the process of living, rather than just existing.
Client: Yeah, I don’t want to spend the rest of my life in bed. I want to be married again, I want friends that I care about, I want to be out doing things.
Therapist: So what would you like to do next? or So how can you start to move closer to that?
[If needed, you can progress to asking more specific questions about next steps, but starting with a broad and open-ended question helps the client to get creative and also helps him to take some of the responsibility for this new approach. Ideally, the client is generating ideas – with some help and shaping from you – and taking an active stance in making a plan that really works for him. Remember, throughout the rest of this conversation, you are validating the challenges of doing something different while also reminding the client that this is what he wants, this is important. Hopefully at this point in the conversation you have transitioned from being the one pulling the cart along to a bystander encouraging the client as he takes the next step forward.]