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10.1177/1066480705278723THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2005Sperry / THERAPEUTIC INTERVIEWING STRATEGY

❖ Couples, Families, & Health

A Therapeutic Interviewing Strategy for Effective Counseling Practice: Application to Health and Medical Issues in Individual and Couples Therapy

Len Sperry Florida Atlantic University

Training to become an effective provider of health-focused counsel- ing with individuals and couples can be a daunting challenge given the complexity that medical and other health issues adds to the coun- seling process. To facilitate the process of learning to do such health- focused counseling, a relatively straightforward interview strategy, derived from cognitive behavior analysis system of psychotherapy, is described. The strategy is then illustrated with a couple experienc- ing relational discord, which is exacerbated by one spouse’s chronic illness (i.e., systemic lupus erythematosus, commonly referred to as lupus).

Keywords: interviewing; medical issues; couples; couples ther- apy; cognitive behavior analysis system of psycho- therapy (CBASP)

Learning to do effective individual psychotherapy as wellas couples and family counseling/therapy is a complex undertaking for most trainees. When health and medical issues are part of the clients’ presentation, another level of complexity is added to the treatment process. Needless to say, guiding trainees to deal with health issues, along with psy- chological considerations in the counseling process, can be a daunting challenge not only for trainees but also for their instructors and clinical supervisors. Fortunately, focused therapeutic methods and techniques continue to be devel- oped, and some of these appear to offer considerable promise to the practice of health-focused counseling and psychother- apy (Sperry, in press; Sperry, Lewis, Carlson, & Englar- Carlson, 2005). One of these methods is a straightforward and easily learned interviewing strategy derived from cogni- tive behavior analysis system of psychotherapy (CBASP). CBASP was developed by McCullough (2000) and initially

was targeted to the treatment of chronic depression. Recently, this approach has been extended to several other mental disor- ders as well as to psychological issues involving parents, children, and couples (Driscoll, Cukrowicz, Reardon, & Joiner, 2004).

To date, this approach has not been extended to health issues. Accordingly, this article endeavors to describe the approach to medical and health issues that I have found useful with individuals and couples. The article begins by briefly describing a nine-step interview strategy that adapts and extends the method described by McCullough (2000). Then it applies this strategy to medical and health issues that arise in the context of counseling. Specifically, it illustrates the use of the interview strategy with a couple experiencing relational discord, which is exacerbated by the wife’s chronic illness, systemic lupus erythematosus (SLE), commonly referred to as lupus. A transcription of a conjoint session demonstrates the use of this interview strategy.

A NINE-STEP INTERVIEW STRATEGY

The nine-step strategy functions as a “cognitive map” in the counseling process. The map guides the counseling pro- cess by providing a focus or sense of direction for therapeutic discussion. Another way of thinking about this interview strategy is that it can be likened to training wheels on a bicy- cle. Counselors and trainees can use this basic therapeutic strategy to process situations and issues as they arise in any counseling context, whether it is a single, unscheduled 10- to 15-minute encounter or in scheduled sessions that are part of ongoing counseling. In a longer counseling session or ongo- ing series of sessions, the nine-step interview strategy is uti- lized in a cyclic fashion (i.e., repeating the nine steps for each

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situation, conflict, or concern of the client). In short, this ther- apeutic interview method becomes the core strategy for the entire counseling process.

The cognitive map consists of nine steps in the form of questions initiated by the counselor or therapist. These nine steps are as follows:

Step 1: Can you describe what happened? Step 2: What was your interpretation of [your thoughts about] the

situation? Step 3: What were your behaviors? [What did you say, what did

you do?] Your feelings? Step 4: What were your expectations [what did you want or hope

would happen]? Step 5: What actually happened? Step 6: Did your behaviors and thoughts help or prevent [hurt]

you from getting what you wanted? Step 7: It didn’t sound like it did. Can we analyze this together to

see what happened and what might be different? Step 8: How did your behaviors [thoughts/interpretations] help

get you what you wanted? or How did your behaviors [thoughts/interpretations] prevent [hurt] you from getting what you wanted? or Were your expectations realistic?

Step 9: What thoughts might have better helped you get what you wanted? or What behaviors might better help you get what you want the next time a situation like this comes up? or How can your expectations be modified to be more realistic?

CASE ILLUSTRATION: A COUPLE WITH RELATIONAL DISCORD AND

SYSTEMIC LUPUS ERYTHEMATOSUS

Carol and Tom were married for 6 years and had been experiencing relational difficulties for nearly 2 years. That coincides with Carol’s diagnosis and the beginning of her treatment for SLE. It is noteworthy that her diagnosis was made during the course of fertility treatments she had been undergoing for some 3 years. The couple’s hopes and plans for a family seemed to all but disappear as her illness was diagnosed and appeared to take center stage in their lives. Even though her doctors told her that she had a milder form of the disease, Carol intermittently experienced severe joint pain and headaches, along with chronic fatigue. Most of the time she had little energy to do even routine chores, and it soon became clear that continuing with her professional work was becoming all but impossible. On the advice of her physician, she had resigned her elementary school teaching position a year and a half ago. She could still do basic things such as fix- ing meals and light cleanup but not much more. Nevertheless, there were days when she felt energetic enough to think she was actually getting better and would set out to take on tasks she had easily accomplished in the past. Inevitably, she would overdo it and exacerbate her condition. Although relational discord occurred occasionally before the diagnosis, it pre- dictably had increased as Carol’s symptoms worsened and were exacerbated by various demands in the home and in the relationship. Although Carol had largely accepted her illness, Tom had not. On one hand, he accepted the doctor’s assess-

ment that SLE would limit Carol’s functioning, but on the other hand, he expected that she would continue to do many things for him that he had become accustomed to in the past. Her submissive style and lack of assertive communication only seemed to compound matters.

The couple was referred by Carol’s physician for couples therapy to a counselor with training and experience in health- focused counseling and psychotherapy. The counselor quickly recognized that Carol’s illness not only impaired her functioning but also magnified the influence of her personal style of submissiveness on relational dynamics which pre- dictably negatively impacted their functioning as a couple. He had two therapeutic goals. The first was to increase the couple’s understanding of their personal and interpersonal dynamics and the interplay and impact of SLE on them as individuals and as a couple. The second was to modify their relational pattern vis-à-vis the challenge of the chronic illness they both faced. Because of its effectiveness with similar health-related cases, he chose to begin the therapeutic process with the nine-step interview strategy.

The following transcription describes the application of this approach during their fourth conjoint session:

Counselor: It’s nice to see the two of you again. How have things been lately?

Tom: (Silence) Carol, as usual, seems to be waiting for me to take the lead. But I would really like it if she would respond to your question.

Counselor: I hear you, Tom. You don’t feel that the responsibility for responding should be yours alone, and you wish that Carol would take the initiative sometimes.

Carol: Sure, I’ll start off. Well, what happened is that Tom came home from work, and he was in a bad mood. Maybe he had a bad day at the office. Whatever it was, he was grousing about dinner. Earlier I had decided not to cook and hoped that we might go out for a change. After all, I had a little more energy than usual that day, which doesn’t happen too often. I had spent a few hours cleaning the house that afternoon. and I was starting to drag and my joints had really become inflamed. My medication doesn’t help at times like that and I was too fatigued to cook dinner. He told me he was hungry and tired and wondered why dinner wasn’t ready.

Counselor: What did this mean to you? What were you thinking?

Carol: Well, I thought that when I’m not feeling well, that I shouldn’t have to cook a meal, but I also knew better than to presume we’d go out to eat without asking Tom first. I also thought that he seldom appreciates the housework I do when I’m feeling well or really badly. I also assumed he was angry with me for being inconsid- erate of the hard day he probably had at work and that he was tired. This made me feel guilty. So I immedi- ately apologized for not being considerate and started to put together a quick meal. But I let him know by the

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tone of my voice that I was upset and I started tearing up, just on the verge of crying.

Counselor: What actually happened? Carol: Tom became frustrated that I was upset, and we got

in an argument. He had no idea what was happening inside me. We ended up ordering takeout and ignored each other the rest of the evening.

Counselor: What did you expect to happen? Carol: I wanted him to hug and kiss me when he got home,

and then I wanted to relax and go to our favorite restau- rant. I really wanted some acknowledgment of the work I did around the house and the pain I endured in the pro- cess. I hoped that we could enjoy dinner out and relax after a long day.

Counselor: Did you get what you expected? Carol: I clearly didn’t get what I wanted. Counselor: Tom, please tell us your version of the story. Tom: All right. Well, I walked through the door, and Carol

was lying on the couch watching TV. There was noth- ing in the kitchen for dinner like there usually is, so I asked her when we were going to eat. She got all upset and started apologizing and crying. For the life of me, I couldn’t understand why she was so upset. After I picked up our food order, she told me that she had wanted to go out. Then we started arguing.

Counselor: So what was your interpretation of that situation?

Tom: I thought that she got upset again for no reason. When I finally figured out she wanted to go to dinner, I couldn’t understand why she didn’t just tell me that she was tired and in pain. After all, even though we’ve been married 6 years, I still can’t read her mind. Very well, anyway. I thought that I did not need her picking a fight after I had such a long day. So I went and picked up some takeout and sat on the couch to watch the evening news. My tone of voice may have been a little gruff, but I wasn’t upset with her at first. I guess I didn’t say much to her the rest of the evening because I was in a bad mood after having an awful day at work.

Counselor: What did you want to happen when you got home that night?

Tom: I just wanted to come home after a hard day at the office, have a good meal, and take it easy for the rest of the evening. It didn’t really matter to me if we ate out or ate at home. Instead, I arrived home, got into an argu- ment with my wife, and went to sleep frustrated and angry.

Counselor: Did you get what you expected and wanted? Tom: Absolutely not. Counselor: It seems that both of you wanted to spend a

relaxing evening together. What I also heard is that Carol wanted you to appreciate the work she did around the house, especially when it triggered so much pain and fatigue. And Tom expected Carol to tell him directly her idea about [dinner], whether it was to eat at home or go out.

Tom: Yeah, she never tells me what she wants. Instead, she gets upset and leaves me clueless. I wouldn’t have

objected to going out to eat, but I didn’t know she wanted to.

Carol: Well, you were so irritable and gruff that I assumed you were mad at me for not having dinner ready the minute you got home. You don’t even notice that I was in pain from spending half the day cleaning. You know that doing that usually exacerbates my SLE.

Counselor: It’s clear that you are both still feeling frus- trated with the way this turned out. I’d like to process this situation with you with the hope of coming up with some alternate interpretations for it. (Pause). Tom, you wanted to come home, have dinner with Carol, and set- tle in for the night, is that right?

Tom: Yes, but I also wanted her to tell me she was in pain and her plans for dinner rather than getting her feelings hurt for no reason.

Counselor: Let’s take a closer look at these interpretations. First, you thought or concluded that she was upset again for no reason. Did that interpretation help you or hurt you in terms of getting what you wanted?

Tom: (Pause) Well, I guess it hurt me. I assumed she was being unreasonable and noncommunicative, and that just made me angry.

Counselor: Can you think of another interpretation that might have helped you get what you wanted?

Tom: Maybe I could have concluded that she was upset and probably had a reason for it, which means I should try to find out what’s wrong. That would have helped me because I wouldn’t have become so angry and maybe we could have talked calmly about things rather than argue.

Counselor: Okay. Let’s look at your second interpretation. You said that you didn’t appreciate her picking a fight with you for no reason. Did this interpretation help you or hurt you?

Tom: That one really hurt me because I assumed again that she was the one who was being unreasonab1e and that I had nothing to do with it. I guess I was being selfish because I was irritable and angry about my bad day at the office. Maybe if I had been more sensitive and observant of her fatigue and pain—and the clean house—I wouldn’t have hurt her feelings. That would have avoided the argument.

Counselor: Next, you said that your tone of voice was unpleasant when you got home. Is that correct?

Tom: It is. (Pause). I think I follow what you’re getting at. I guess it hurt me because it probably has made her think that I was angry with her. Maybe I should have made it clear that I wasn’t upset with her right as soon as I got home, instead of the way I treated her.

Counselor: Good. You also said that you picked up some takeout and then ignored her for the rest of the evening.

Tom: Yeah, and that hurt me because it hurt her feelings even more, which made everything worse. If I hadn’t been so stubborn and talked to her about it, we might have resolved it within a few minutes instead of ruining the whole evening.

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Counselor: Would changing this behavior have also helped you achieve your other expectation, which was for her to tell you what she wanted?

Tom: That’s interesting. Maybe it would have helped. But ultimately that would really depend on her. I guess that may not be a realistic expectation

Counselor: I can understand that you want her to feel com- fortable telling you what she wanted, but it may not be a realistic goal for you because it relies on her behavior, which, as you know, is beyond your control. Can you think of a related but more realistic expectation?

Tom: Sure. I guess it would be that I wouldn’t dump my own bad mood on her. That would probably make it much easier for her to tell me what she needs and wants.

Counselor: That follows. I could anticipate that the alter- natives you came up with might help you achieve this.

Tom: Yeah, I can, too. Counselor: Okay, Carol, in this situation, you wanted to go

out to dinner with Tom and then spend a nice evening together. You also said that you wanted him to acknowledge your pain when you exert yourself clean- ing the house. Is this right?

Carol: Yes, it is. Counselor: The first interpretation you gave was that you

really should have known better than to plan to go out without first asking Tom. Did this thought help you or hurt in terms of getting what you want?

Carol: (Pause). Well, it did hurt me because it made me feel like I had to ask permission from him instead of just telling him that I would like to go out to dinner. I guess a better interpretation would have been to think that he would be tired from a hard day at the office and would probably enjoy eating out somewhere.

Counselor: That sounds reasonable. Your second interpre- tation was to assume that he must be angry with you. Did this help or hurt you in terms of getting what you wanted?

Carol: Well, it definitely hurt because my own feelings were hurt when I thought he was angry. If I had just thought that he might have had a bad day and his irrita- bility and moodiness had nothing to do with me, I prob- ably wouldn’t have gotten so upset.

Counselor: Sure. Your third interpretation was that Tom didn’t even care about all the time and resulting pain from cleaning the house. Is that accurate?

Carol: Uh hmm. Again, this one hurt me in getting what I wanted because I ended up feeling so bad and upset. Instead, I should have thought that he just walked in the door and probably didn’t have a chance to even notice the cleaning that I had done or my pain and fatigue. Then, I would not have been upset, and maybe he wouldn’t have gotten so frustrated and we could have had a nicer evening together.

Counselor: Will this new interpretation help you with your expectation, which was for him to acknowledge your work around the house?

Carol: Well, it might, but I can’t really make him say any- thing no matter what I do. So maybe it’s not a realistic expectation

Counselor: I agree, you can’t control anyone else’s behav- ior. Can you think of an alternate expectation?

Carol: I guess that one of my expectations might be to shut down verbally when I’m not feeling well and tired because it too often leads to unnecessary arguments.

Counselor: Sounds good. Hopefully, these new interpreta- tions might help you.

Carol: Yes, it probably will, assuming I can actually do it. Counselor: You also said that you immediately apolo-

gized to him for not being a good wife and then began trying to quickly put together a meal. Is that accurate?

Carol: Yes. I know what I did wasn’t helpful because it only made him more upset with me because he had absolutely no idea why I was upset. It would have been much better if I had just told him that I understood that he had a tough day at work and that I wanted to go out for dinner.

Counselor: You also noted that you let him know you were upset by your tone of voice and that you were on the verge of crying. Did this help or hurt you get what you hoped for?

Carol: It hurt because he usually ignores me when I act like this. I should have just told him about my pain and fatigue. Then we probably could have resolved things much sooner.

Counselor: You’ve both done some really good work today. What is each of you thinking right now?

Carol: Well, it’s clear that we both make assumptions about the other instead of just talking. And it seems to lead to discord rather than harmony.

Tom: I agree. It seems we are so accustomed to fighting with each other that we expect negative reactions and emotions from each other when what we really want to do is have a relaxing time together.

Counselor: Was working through this situation helpful? Tom: Definitely. I now see how I contributed to the argu-

ment and that blaming her was off the mark and made things worse.

Carol: It was helpful to realize that my being submissive and nonassertive can actually hurt our relationship. I’ve been this way in the past, assuming that being submis- sive would reduce the chance of us fighting. But it actu- ally promotes discord.

Counselor: A real irony. (Pause). Is what you’ve learned today applicable to other situations?

Tom: It sure makes me more aware of how I come across to her. I’ve got to find other ways to let her know about how things get to me at work without taking it out on her and hurting her feelings. She might even feel more comfortable asserting herself with me then.

Carol: It’s becoming clearer to me that if I could be a bit more assertive and tell Tom when and how my SLE is acting up, we would probably get along much better.

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Counselor: Well, we’ve done a lot this session. And it seems like things are going in the direction you hoped they would.

CASE COMMENTARY

The case demonstrates that an illness or health concern can impact individual and couple functioning while also magni- fying the influence of the personality style of one or both spouses. In this instance, Carol’s submissive and nonassertive style amplified the effects of her chronic illness, which together served to increase relational discord. Using the inter- view strategy facilitated an exploration of the thoughts, behaviors, feelings, and expectations of each spouse in a nonthreatening manner. Furthermore, the strategy “surfaced” the unrealistic expectations that each spouse had for the other in a way that engendered little or no resistance. This was an important consideration given that other interventions and approaches to eliciting and processing such dynamics can and often do trigger resistance. It is also worthwhile to note that Tom’s recognition of his unrealistic expectations of Carol should reduce his resistance to accepting her illness, some- thing that has heretofore fueled their relational discord.

CONCLUDING NOTE

The interview strategy described and illustrated in this article appears to have considerable promise for individual

therapy and couples therapy/counseling, which involves medical and health-related issues. The fact that it is a straight- forward and easy-to-use “map” for guiding the counseling process in the midst of complex issues and concerns makes it a promising option for use in educational programs that train counselors and therapists in addition to its clinical utility for experienced counselors and therapists.

REFERENCES

Driscoll, K., Cukrowicz, K., Reardon, M. & Joiner, T. (2004). Simple treat-

ment for complex problems: A flexible cognitive behavioral analysis

approach to psychotherapy. Mahwah, NJ: Lawrence Erlbaum.

McCullough, J. (2000). Treatment for chronic depression: Cognitive behav-

ioral analysis system of psychotherapy. New York: Guilford.

Sperry, L. (in press). Psychological treatment of chronic illness. Washington,

DC: American Psychological Association.

Sperry, L., Lewis, J., Carlson, J., & Englar-Carlson, M. (2005). Health pro-

motion and health counseling (2nd ed.). Boston: Allyn & Bacon.

Len Sperry, M.D., Ph.D., is professor of mental health counseling and coordinator of the doctoral program in counseling at Florida Atlantic University, Boca Raton.

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