It's happened to us all at one time or another. We've just finished what felt like an incredible therapy session. Our client was borderline somnambulistic and walked out with a completely re-arranged set of standards. There's nothing that will ever make that person pick up a cigarette again. Heck, if you had to stake your reputation on any one patient, you'd want it to be this one. As he walks out the door, you can't help but wonder if next week's follow through session is going to be necessary. And then, just a week later, your "wonderchild" walks in carrying a cigarette...

Before he even has a seat he's blaming his "insensitive" wife for smoking around him, or maybe it's the guys at work, or the bowling league, who made a joke out of his quitting and spent the week offering him a smoke. It's almost as if they all went out of they're way to try and sabotage his efforts. And the truth is, they probably did. For more than one reason. And it's a definite variable that needs to be addressed in any quality session.

Traditional psychology usually tells us to avoid shifting blame. They advise us that any good therapy model relies on focussing the responsibility for problems on the client and allowing him (or her) to figure out ways they can make changes. Unfortunately this model often leaves a client accepting responsibility (and the accompanying guilt and shame) for problems that are out of their control.

When I ran my center, we used to draw up charts on each of our clients at the end of every session. The sheet was pretty simple. Along the top we had a general name, client number, etc. Directly below that we had a half page or so where we wrote out our impressions on the client, what we felt were his or her needs and what issues the client felt (s)he was interested in addressing. We then had a long checklist of typical psychological issues (denial, transference, self pity, self esteem issues, etc.). Next to each we would place a number (from 1 to 5) rating our "gut feeling/first impression" of the client and their attitude towards the problem. 
On the back of the sheet, we did a chart that had a way of focusing our future efforts in the right direction. During our first session, with very few exceptions, the client had been asked to fill out a similar chart, which they took home with them, to use as leverage in convincing themselves that they didn't have as bad a problem as they thought. We called it, appropriately enough, our "cop out" sheet. 
Basically, the goal was to put on paper all the issues relevant to the problem. The sheet had a vertical line drawn from the top middle to the bottom middle of the page. From the right middle to the left middle of the page, we also drew a horizontal line. Basically the page was divided into four corners by a large cross. We would then have the client label each corner so we could refer to them later on in therapy. In tiny letters on the top left hand corner of the page we would write the letters "PN". These letters stood for "Positives to Not quitting". On this corner the client would list all the reasons (s)he felt the behavior in question was good. 

I still use this method, and when I get to this corner I explain that the client should list every reason they would give me if it was their responsibility to convince me to take up the behavior. I explain that nobody, including me, will ever see the list, so it's important that they be completely honest, to the point of being brutal, with themselves. When I do my own version of the chart, after they leave, I'm left with trying to guess at what motivates them. I list every reason I think the person has to continue doing whatever it is we're talking about.

The top right corner has the letters "NQ" written (Negatives for Quitting) and they list there the fears they feel about quitting. A smoker might list items like "I might gain weight", "if I commit to quit and fail, my friends will laugh at me" etc. I keep in mind the fact that I'm going to write out a similar list after the client leaves, and make it a mental goal to try and draw out as many of these reasons as I can during the pre-talk. I explain to the client that any fears that don't come out now, and are adequately dealt with, will merely be lurking inside, just waiting for the right moment to pop up. If, say, the smoker doesn't mention that they're sure they'll loose the "cool dude" image (not as common nowadays), they'll use that as an excuse to pick up a cigarette next time they're headed for a date or party.

The bottom left corner lists Positives for Quitting (PQ) where the client lists all the good they think will come from quitting, and finally the bottom right hand corner lists the "NN" issues (Negatives to Not quitting). This corner lists the "terrible stuff" they assume will happen if they don't quit.

Once the sheet is finished, the client is told to take it home and put it in a very conspicuous place. I usually suggest placing it on the mirror where they brush their teeth in the morning. Besides serving as a reminder that they have a goal they're working on, it helps them to keep a good focus on why succeeding, one day at a time, is so important. The list I'm going to make once the client leaves also helps me to better understand the client and prepare for my next session. 

This page ( I guess I tossed it in here as a "free-be" ) is a very powerful way to focus a session. As soon as the list is finished, I ask the client to tell me any of the PN issues they feel are valid. Usually I understand these issues well enough to diffuse their power.  It usually takes a bit of "deprogramming" to explain, for example, that it isn't the smoking of a cigarette that relaxes you. Nicotine is actually a stimulant. What's really happening is the client is taking a deep breath, which relaxes them, but 10 or 15 seconds later, when the nicotine that is now in the lungs reaches the brain, the body jumps up in the other direction, becoming more aggressive and jittery. To help fight the rising adrenaline flow, the smoker usually takes another puff, and celebrates the fact that the cigarette was there to help "fight" the stress. Truth be told, if they had taken the deep breath without the nicotine, their relaxation would have been much more complete and would definitely have lasted longer. Once the PN and NQ issues are addressed, the client is left with plenty ammunition to "do their thing". Having the client complete the Cop Out sheet leads me to another exercise that goes right to the spouse/peer issue.

After understanding the real pros and cons, I ask the client to list all the obstacles they feel they'll need to overcome in addressing the issue. I usually do this by having them complete sentences like, "The problems I foresee having to struggle with in trying to stop smoking will be..." or, "The influences I'll have the most trouble fighting in stopping my smoking habit will be...". Most of this list parallels issues we talked about in the "cop out" sheet. 

Once the list is completed, I have the client look it over carefully and add any new ideas that come to mind. I then ask the client if they included peer pressure in this list. Weight losers need to be aware of the fact the spouses might fight them on the issue and start buying ice cream for no reason. I guarantee smokers that they'll find their "friends" will be offering them cigarettes a lot more often. Even phobics are told to expect people close to them to want to talk a lot about the problem, or even try to force the client to unreasonably have to face it.
No, I'm not trying to be mean, or create an air of cynicism. I usually explain to the client that we all, by nature, feel safe in our "comfort zones". Change is scary to everybody. I'll tell them that they need to understand that this "promoting the status quo" attitude is deep rooted and reflects what our mind perceives as "security". I then explain that spouses, siblings, workmates and other relationships will all be faced, subconsciously, with the reality of something changing. Some will feel, deep down inside, that the fact, say, that the client stopped smoking simply makes the spouse, who can't quit, look like a failure. Overweight workmates will delight (at a subconscious level) in watching dedicated clients prove they are no better than "the average guy" by giving in to temptations. 

Even family dynamics dictate that often times the best meaning relatives find themselves threatened by parents or spouses that are making changes. It's not uncommon for, say, a mother who's spent years nagging and complaining about everything to discover, soon after she's made a super human effort to "mend her ways", that one of her kids "picks up the torch" so to speak and starts causing static around the house. It's kind of like an excessive compulsive who stops smoking only to find they pick up nail biting. It's what happens when we address symptoms (smoking) rather than problems (excessive compulsion). The symptoms can merely shift.

I'll tell my client to be aware, and ready for this to happen.  I'm also quick to explain that regardless of how blatant the attempt to sabotage might seem, these efforts are rarely being done maliciously. I explain that the people offering to buy them a piece of cake are actually fighting the same "force" of their inner minds that (s)he's been dealing with for years. That compulsion to "keep things the way they are". That need to make sure all the ducks are still sitting in the same rows. I suggest to my client that they be on the look out for this behavior, but more importantly, that they address it, immediately, when it comes up. I suggest that they learn to ask, nicely, but firmly, that their friends not try to make them fail. I usually ask smokers to actually practice once or twice, in front of me, saying words like, "Bob, you know I'm trying to quit. Please don't offer me cigarettes. I really need your support here." I suggest they also find ways to buffer this with comments to the effect of, " I realize you weren't trying to be mean, but I do need all the help I can get here." The very act of "standing your ground" has a strong therapeutic effect on a person. It makes them feel they are fighting a winning battle.

Unfortunately, not all the aggressors will change after being asked to. I've had clients report of workmates or friends that almost seemed to be plotting their failure. To best address these situations, I make a point of including in my therapy strong images of the client in most of the "dangerous" situations where these issues might arise. I have them see themselves strong enough to overcome and usually anchor it in with a powerful, almost aggressive suggestions that "it feels so good to know you are the master of your own life, doesn't it?" I also include images of them walking up confidently to a crowd of smokers, say, at a party, because "you know you're stronger than all that, don't you? You know there's nothing they can do that will make you want to give in to cigarettes. How does that make you feel?" etc. 
But I don't stop there. When I had the center in Los Angeles, we used to have a private phone line with an answering machine attached to it, running 24 hours a day, on a toll free, 800 phone number.. I would ask my clients to watch for these situations where they felt tempted but overcame, and instructed them to keep a list of them, and call my "private therapy line" as soon as they could, to report their victory to me. The toll free number on this line left them without any excuse for not calling. They could call from pay phones or at work and never have to pay a penny. Every morning, and in the evening before leaving, my secretary would type up all the new calls for me, and file them individually by client. That way, the next week, when the client walked in, I could celebrate with them based on this "daily companionship" created by a machine I never even listened to. 

This machine also served a second purpose. I always left clients with a strong image of "hanging in there". I always explained that the only person who could beat them was themselves. I'll make the observation that if, say, they went off their diet, or failed to exercise one day, they could either use that as an excuse to give up and go back to where they had been, or they could accept it as a set back and see what lessons they could learn from it. I recommend that as soon as they could, after realizing they had given in to temptation, they call my line and tell me; 1) what they did; 2) what caused it; 3) what they would do from now on to keep the problem from beating them. This, again, offers a therapeutic influence that can be built on at our next session. 

Besides the commitment to "fess up" to their actions, it also helps them to keep the issues in perspective. Verbalizing problems tends to keep them from becoming imagined monsters. The next week, when the client comes in for their appointment, I can point out that "all your setbacks seem to be triggered by social situations (or stress, or taste, etc)" and go on to aim them in the right direction with appropriate metaphors.

Unfortunately, now that I'm on the road a lot and don't get the luxury of weekly visits with my clients, I recommend that they keep a daily journal. I strongly suggest they carry with them a small notebook and list every time they feel tempted, and how it went. At the end of the day, I instruct them to list, on a piece of paper (usually next to their "cop out" sheet), how many times they beat temptation and how many setbacks they experienced.  I explain that the more times they actually put their victories on paper, the more their mind will accept that they are "constantly victorious". I'll explain that without taking the moment to validate the victory in writing, it won't be long before their mind will start taking victories for granted, and won't even notice any change. 

There's a very powerful metaphor I'll always toss in here. I'll explain that if I had started lowering the air conditioning in the room slowly as soon as they sat down, chances are pretty good we could have made the room quite cold without the client ever noticing. "The mind", I'll explain, " is much more aware of sudden changes. Any change that happens gradually tends to be ignored." I'll tell the client that without a list of victories, and without watching their list of setbacks becoming smaller and smaller (notice the inherent suggestion that there's nothing wrong with having an occasional setback), they may never realize just how well they are doing.

This list or call system serves another very powerful purpose. Having them make a game out of watching for temptations diffuses any possible "time bombs" I didn't address in therapy. It's almost as if I've enlisted their subconscious mind, and it's natural drive to accomplish, as my ally in having the client succeed. It also tends to make these awkward situations more tolerable. Clients regularly tell me they almost found themselves looking for "times to go out and win". Instead of spending their lives trying not to come anywhere near a buffet or candy isle at the grocers, the client now prides him or herself on how many times she walked past the chocolate and managed to not buy it. Trust me, it's a very powerful technique.

Finally, when dealing with stubborn spouses and workmates, I always suggest to the client that it won't be long before they'll give up. After a week or two of trying, most of them will accept the fact that the client is "a changed person". I tell them that that's a great time to casually seal their victory by suggesting they try changing, because it really isn't as difficult as it may seem. I jokingly mention that if they want to tell these antagonists to look me up, I'll be glad to help them out, but even if (s)he doesn't refer them to me, it helps "close the book" on the issue when they are willing to stand as the authority on changing and try to help others get there as well. Yes, this borders on being an unethical way to embed a crass commercial appeal into a therapy session, but considering the number of referrals I get from satisfied clients, I guess it works. 
Heck, I look forward to antagonistic spouses and workmates. My only concern is that I make sure my client never does anything to offend my future business.