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Terry Soo-Hoo, Ph.D. - Guest
Terry Soo-Hoo, Ph.D. is currently professor at the California State University East Bay in the Marriage and Family Therapy Program, and was the Clinical Director of MRI in Palo Alto. He completed his Ph.D. in clinical psychology at the University of California, Berkeley and is Board Certified in Family and Couples Psychology (ABPP). Prior to university teaching he devoted over twenty years as a psychologist in Community Mental Health Services in San Francisco working with a diverse range of people with many different psychological problems. Terry's publications include topics on multi-cultural issues in psychotherapy and consultation, brief therapy and couples therapy. He has special interests in the area of innovative culturally relevant approaches to psychotherapy. He has also provided extensive presentations, training, supervision and consultation on these topics to agencies and other professionals in many countries around the world. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy at the Institute for the Advancement of Psychotherapy. We provide training in evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in evidence-based approach with our Lifespan Centers, center for Children and Center for Adolescents, where all the therapists are working systemically. Our Center for Couples, where all the therapists are using emotionally focused couples therapy and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma, and our center for ADHD and oppositional and Conduct Disorder clinic, where we're integrating those four approaches. In the Institute we have our licensed experienced therapists, and for those in financial need, we have an associated nonprofit Bay Area Community Counseling where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training and one-way mirror trainings in family systems. To learn more about trainings, treatment and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501 C3 nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (02:20):
Today I'll be interviewing Terry Soo-Hoo PhD, who is currently a professor at the California State University, East Bay in the Marriage and Family Therapy Program, and he was the clinical director of the Mental Research Institute in Palo Alto. Terry completed his PhD in clinical psychology at the University of California Berkeley, and he's board certified in family and couples psychology. Prior to university teaching, he devoted over 20 years as a psychologist in community mental health services in San Francisco, working with diverse range of people with many different psychological problems. These publications include topics on multicultural issues and psychotherapy and consultation, brief therapy and couples therapy. He has special interest in the area of innovative, culturally relevant approaches to psychotherapy, and he has provided extensive presentations, trainings, supervision, and consultation on these topics to agencies and other professionals in many countries around the world. Let's listen to the interview.
Keith Sutton, Psy.D. (03:20):
Well, hi, Terry. Welcome.
Terry Soo-Hoo, Ph.D. (03:22):
Yes. Glad to be here. Thank you for inviting me.
Keith Sutton, Psy.D. (03:26):
Yeah. Thanks for coming on. So Terry, I know a little bit about your work and we had talked when you were down at the mental research Institute in Palo Alto. Recently we've been chatting about you maybe doing an event for the Association of Family Therapists in Northern California on your model for working with clients and in a cultural competency way. You'll have to tell me again how you term it, but first I would love to hear about your path to doing this kind of work and your evolution of thinking.
Terry Soo-Hoo, Ph.D. (04:04):
Sure. Yeah I go way back to the late 1970s, I started by finishing my master's degree in counseling in San Francisco State University and I started working in child family clinic in Chinatown and started to really try to apply what I was learning. I became very frustrated at the time because my main training at the time was psychoanalytic and psychodynamic theory and what we discovered is that it wasn't working well with the immigrant population. We were struggling with it. It was a very traditional, for children's play therapy, very psychoanalytic type of play therapy. Even though we had some successes, oftentimes they would take a long time. And for every successful case we had that took over a year or sometimes two years, there were a number of cases to drop out after a few sessions because they didn't want to stay in therapy for over a year or so. I started to get the feeling that maybe something else could be more effective in a shorter period of time. So that was sort of one of the experiences I had to shape my view of the work. The other major impact I had in that kind of work was one incident where I was talking to a Chinese mother, an immigrant mother, about her five-year-old son. My supervisor at the time, who was very traditional psychoanalytic, started instructing me to tell this mother that her son had an oedipal complex. And I was supposed to explain to this mother, and my Chinese wasn't that good at the time, that her son had this sexual attraction to you and wanted to get rid of his father in order to possess her more fully.
Terry Soo-Hoo, Ph.D. (06:35):
And I remember after I finished saying that, she looked at me like I was crazy. That had an impact on me, realizing this doesn't seem to be working well in this population. In retrospect you could say, well, maybe I could have done it more skillfully, maybe I could have presented it in a different way and stuff like that. But, my sense of it is that no matter how I presented it, the idea was not very acceptable. It seemed like it was fitting. It just didn't seem to fit her culture perspective. So I went to UC Berkeley to get my PhD thinking I would find the answer there, at the top school. Unfortunately, the first year I got more psychoanalytic training and it was very psychodynamic at the time. This time it was called ego psychology. But I still didn't feel very satisfied with what I was getting until I took a course called Strategic Therapy by this guy named Jim Coyne, who was teaching at MRI at the time. And I didn't know anything about it. I just liked the idea of strategies that work. So he said something very profound and it's really stuck with me. He said that most people who come to therapy are not sick or pathological. But most people who come to therapy are stuck not finding the right solutions to their problems. So the goal of therapy wasn't to cure sickness or pathology. The goal of therapy was to help people get unstuck and that made so much sense to me.
Terry Soo-Hoo, Ph.D. (08:39):
Then I started to explore the idea of how people got stuck really was related to their cultural context. Therefore, in order to get help people get unstuck, we have to work within their cultural context, so the solutions had to fit their culture. I went to MRI to do an intensive training. I worked with the main founders, Paul Bosnick and John Wheatland Fish, and did an intensive one year training there. After I finished, I started to apply this method everywhere I worked. For 20 years, I've worked in community mental health and inpatient outpatient residential treatment, children, families, the entire gamut of the diversity of different cultures, different races. Everywhere I went, I started to apply this approach with some modifications. I started adding my own modifications to it. In fact, it was so successful that I started a consultation group. Clinicians from all over the city and in the county of San Francisco came and brought their most difficult cases. I would offer suggestions and ideas, and it was extremely successful and people found it very helpful.That lasted for a few years. Then I left community mental health and I started teaching at the university level. I taught at four different universities and I'm now currently at Cal State East Bay where I continue to modify and adapt this method.
Keith Sutton, Psy.D. (10:31):
Great. And particularly I'm always interested in this because I did some trainings with Karen Schlanger with the brief team at MRI. Dick Fish came in to say hi, but he wasn't there much anymore and then I worked with the strategic team with Eileen Barbaro for almost a year. I've always wondered about strategic and this group at MRI. Could you talk a little bit about the difference between the brief therapy model and the Jay Haley strategic family therapy model?
Terry Soo-Hoo, Ph.D. (11:13):
Yeah. First of all, I think that the strength of the strategic model, including the MRI model, is that it has very skillful effective techniques and interventions. So in my perspective, that's where the emphasis has been. The emphasis has been these brilliant interventions and these strategies and ideas. In my years of experience at MRI, and after I started working in the field, I started to focus on two areas that I thought really did not get enough attention.The fascinating thing is that the successful therapies have these elements in common that people did not talk about. These two elements are, one, there's not enough focus on the humanistic elements of the relationship. That the basic fundamental processes of how the relationships facilitate people's abilities to change and to really benefit from the therapy. So of course, Scott Miller talks about how 30% of the outcome is really connected to the therapeutic relationship, and there wasn't sufficient focus on how any interventions has to be built upon a positive relationship first to be effective. So I started to focus much more on that, my writing, my training, and so on. Well, actually, there are three elements. The second element was not enough conversations about culture. MRI actually saw a lot of different cultures, particularly Spanish speaking, and we did a lot of therapy with LA Latino clients through translators and different ways of communicating.
Terry Soo-Hoo, Ph.D. (13:37):
But then the very few people actually wrote about it, very, people actually talked about the importance of culture. And what I say is you have to enter the client's world, and every client brings to therapy a unique world. Just because you happen to be a similar cultural ethnic background doesn't mean you live in the same world as the client. So we're not just talking about culture either. We're talking about the uniquenesses of somebody's world. Somebody's worldview, somebody's experiences, somebody's value systems and perspectives. There wasn't enough discussion about that. But over and over again, the research is very clear that successful therapies are successful because the therapist is able to work within the clients in the world. And the unsuccessful therapies are partly, many times the results of not being able to work within the clients' unique world.
Terry Soo-Hoo, Ph.D. (14:44):
And so I started to focus a lot more on that in my training and in my writing and I brought that to MRI. The third element that I really felt needed more attention was, again, MRI did it, but did not talk about it enough, and that was to activate the client's strengths. When I do my trainings, I talk about Scott Miller and the four different elements that he says account for treatment outcome success. Where the first element --30% of the outcome-- is attributed to the relationship. Now, only 15% was actually attributed to technique and theory. I think that it's really probably more, but it's the limitation of the methodology. It's very difficult to compare 10 different theories and 10 different approaches and see which one works better. So it hasn't been done. Scott Miller basically says, across all therapies, all therapies work. It has more to do with the skills of the therapist. Unfortunately, we still need more research to clarify what techniques work better. But a huge 40% of the outcome is due to client factors, which is basically two things that it's going to break down to. One is the strengths and resources that the client bring to therapy and two is client motivation. So that makes sense that the more strengths and resources the client has, the more they can benefit from therapy. And two, the more motivated they are, the more likely they'll also benefit from therapy. So the fourth factor, 15% of the outcome is due to placebo effect. I just interpret that as the belief in the therapy and the therapist.
Keith Sutton, Psy.D. (17:00):
That makes perfect sense.
Terry Soo-Hoo, Ph.D. (17:01):
Yeah. The more you believe that the therapy will help, the more you believe the therapist can help you, the more likely you'll listen and take what the therapist says and implement it. The reason I'm presenting this is because in my view, if you activate the client's strengths, all four factors improve. If you activate the client's strengths, the relationship increases, and the techniques and interventions become much more effective. Obviously the resources and strengths the client has enhances the client's motivation. And four, it really creates that sense of belief. When the therapist activates the client's strengths, the client's much more likely to say, "this therapist can help me and I can really follow what this therapist is saying."
Keith Sutton, Psy.D. (18:12):
It sounds like grounded in what you were saying earlier, that looking at seeing the client as stuck rather than a pathology or sick, also assumes that the client is stuck, but has the resources and might just need to get a little unstuck. You don't need to rebuild the whole car. You might help them jumpstart it a little bit or get going in a different direction. As I'm hearing you talking, I'm thinking about when we see clients' strengths, oftentimes they feel seen. We see the person in there or their strengths or where they want to be or who they want to be, and seeing that change already before they've even begun it. Connected to that hope, that's going to strengthen the alliance if the person feels seen and heard then that alliance, like you're saying, is the basis of everything, motivation, and the working relationship -- all those aspects.
Terry Soo-Hoo, Ph.D. (19:18):
Yeah, absolutely. But I also want to add another thing too, in that when we work with students or trainees or interns, what oftentimes they discover is that for many clients, if you only talk about their strengths, then they bounce over to the other side. And then we have to sort of clarify this particular point.
Keith Sutton, Psy.D. (19:40):
Yes, yes.
Terry Soo-Hoo, Ph.D. (19:41):
You know, then they'll say, "but, but, but" and so what we tell trainees and interns is that you really need to help the client to appreciate and acknowledge both sides. It's the struggle that we are helping them with. On the one side, there is this sense of so much capacity, so much potential, so much intelligence and history of successes in certain areas of their lives. And they have the capacity and the ability to really cope and deal with things. But on the other hand, there's a tremendous sense of fear, anxiety, insecurity, just being overwhelmed with crises and things like that. What we say is we need to acknowledge both. We need to help them with the struggle of how to activate the strong part of them so they can cope more effectively with the fear and the anxiety and the insecurities.
Keith Sutton, Psy.D. (20:40):
Definitely. Yeah and it makes me think of motivational interviewing where the assumption is that everyone has ambivalence. There's a part of them that wants change, there's a part of them that wants to keep sustaining where they're at, and really helping to navigate those pieces.
Terry Soo-Hoo, Ph.D. (20:59):
Without getting myself into trouble a little bit, motivational interview has so many connections to MRI and some of the strategic ideas. I don't necessarily want to take away from their work, but there's a connection.
Keith Sutton, Psy.D. (21:13):
Sure. So much was influenced by MRI and I actually want to go back, if it's okay, to that question about the brief therapy team. The way I differentiated was that the MRI brief therapy team focused on that 180 degree change, that the attempted solution has become the problem, then the family or the client is getting stuck. Helping them to do a 180 degree change to become unstuck and create some kind of change in the system, ideally, is going to help with some movement versus the more strategic family therapy where there's a lot more focus on the hierarchy and the more paradoxical interventions, which again, I don't know if that's also with the brief team. The brief team always felt to me like they distilled it down to this element. Strategic had a lot of different pieces going on. But I'd love to get your thoughts because MRI was this place where both were going on. I don't know about when you were there, if they were both going on having the two different mirrors or if that had been combined.
Terry Soo-Hoo, Ph.D. (22:31):
Yeah, I think your observations are pretty accurate that Jay Haley was at MRI, then he left and developed his ideas further. My sense of it is that the Jay Haley version really does focus a lot on the paradoxical disruptions of the pattern. There is that sense of looking to disrupt the power hierarchy and the relationship. He focuses a lot on the function: the symptoms of a function, the disruption of a function.
Keith Sutton, Psy.D. (23:19):
May not be able to go directly at it to you. So that's where those paradoxes come in.
Terry Soo-Hoo, Ph.D. (23:23):
Yeah, that's right. And the MRI model really has more to do with trying to focus on what's not working. The simple view is that the more you do something that doesn't work, the more the situation is perpetuated and the problem continues and it aggravates it and expands on it. So they're much more into second order change, where it disrupts those kinds of interaction patterns that are not working. It's escalating the pattern. So there's a shift in focus. Some of the strategies sometimes overlap. I think that both methods do have paradoxical intention, but the way I teach it in MRI is that unfortunately, people who only have superficial knowledge of strategic therapy or MRI tie it too much to the concept of paradox. In my view, paradox is just a technique. It doesn't define the theory. The theory really is what's not working.
Keith Sutton, Psy.D. (24:40):
Yes.
Terry Soo-Hoo, Ph.D. (24:41):
Because the more you do something that doesn't work, the worse the problem gets. So the theory is how do you stop those interaction patterns that are not working. Then how do you replace them with different behaviors, different strategies that breaks that pattern, and then initiates new solutions, new patterns that work better. So paradox is just one way to do this. I'm not sure if that's even my preferred way. My preferred way has more to do with reframing and changing. The perception and meaning, narrative therapy, causes rewriting your story, changing your narrative. But that's an important aspect of how we stop the interaction patterns that don't work well. You help the client see the situation a different way, which leads them to a different pattern.
Keith Sutton, Psy.D. (25:38):
Yes. Well I'm thinking about how I was reading over one of your articles on single session work, and there was an example that you gave of a Vietnamese woman that you had worked with. I don't know if you would like to, I thought you really went with her worldview and her perspective and built on that with an intervention that ended up being very successful. Can you speak to that at all?
Terry Soo-Hoo, Ph.D. (26:10):
Yeah actually I've read so many articles, you need to give me a better idea.
Keith Sutton, Psy.D. (26:16):
Sure. I can give you more. The father was sick and the daughter was taking care of the father. She was bringing food and so on, and he had experienced trauma from Vietnam. They had moved when she was young, and she had gone to another therapist who said that she needed to individuate and become more independent and that really felt bad to her because she felt like her father would die if she was not taking care of him. There was the mother and I think two or three other kids and telling her to do less, even though there was sort of an enabling part that was going on, that would've of course not worked. But instead you actually encourage her to do more, but in a different direction.
Terry Soo-Hoo, Ph.D. (27:01):
Yeah this is a good example of a number of factors that are important to pay attention to in these types of cases. Culture certainly plays a huge role, but this interaction pattern is quite common. So let's throw out one thing at a time. Basically, the interaction pattern is that the more the daughter took care of the father, the more incompetent the father was, and that is a common pattern. It is a very common pattern in family systems theory. Basically, if you have a very powerful person who plays the competent role, Salvador Minuchin calls this complementarianism, meaning that the flip side is you have an incompetent person and that then sort of balances out. So in order for that system to change, the competent person has to become less competent by taking a step back and allowing the less competent person to step up. This is the common dynamic in many of these kinds of relationship issues, but the cultural element is you can't tell people that. If you could just tell people to stop it then therapy would be easy. So the challenge of therapy is to figure out how you help people change that interaction pattern if you want to see a family systems view of the family structure. You have to do it within something that fits the client's culture that makes sense to the client. And again, it's not just culture, it's their world view, their view of their role. And in this particular case, she's the number one daughter. So therefore her role is the caretaker.
Terry Soo-Hoo, Ph.D. (29:01):
"I'm responsible, I have to do this. If I don't do it, he is going to die. The world's going to collapse." Yes, those kinds of feelings. And the mother has basically abdicated her role because she's given up. “I'm just going to take care of myself, and I just have to take care of the other children.” So if she's left being the sole caretaker, it's very hard to tell her to back off. It's very difficult. So our challenge in our work is: how do you help her see the situation differently and allow her to view the solutions differently? So what we explored with her is what the father really needs. What helped her was the idea that she went to the gym, lifted weights, and did other activities like that. It had personal relevance to her in her world. So I asked: have you ever thought about muscle --how, in order to maintain muscle tone, you need to exercise the muscles? Emotional muscles are the same. Mental muscles are the same. Physical muscles are the same. You need to exercise them because if you don't exercise, they atrophy and deteriorate right away. So he says, “My concern is that your dad is experiencing atrophy emotionally, mentally, physically, and so on.” She says, “Yes, I'm concerned about that.” He replies, “Great, you're concerned. So what do you think we need to do?”
Terry Soo-Hoo, Ph.D. (30:57):
And then I ask her, "have you ever thought about the idea that when you're at the gym, you can ask somebody else to lift your weights for you? And she laughed and she says, "No, that's silly." So I said, "Well, I wonder if you see a parallel of what's happening with your father, that basically you're lifting all the weight. Everybody else is lifting weight. And what happens to him? He's atrophied. So what do you think he means?" She says, "Well, I think he needs to lift his own weight." I said "How do we get him to do that?" Now there is what we call a shift in meaning perceptions about what the issue is. What she would do is she would take food to him three times a day and didn't even let him walk down the stairs in order to eat. And so we said, "let's start small. You know what, if you were to cook meals and make sure that he smelled all the food and open all the doors and just waited and see how long it would take." Well, she wondered what if he never ate? Well, research says one or two days is probably okay. If he doesn't eat for three days, I would be worried. But it didn't take long, as soon as he smelled the food and he realized people weren't walking up to feed him, he went downstairs and started to eat. That was just the first step. Then we built on that, had him do more and more, and then she would do less and less.
Keith Sutton, Psy.D. (32:48):
Yeah, and I think when you went into the writing, you were saying something especially aromatic that smelled so good he wouldn’t be able to resist coming down. And when Lenny did come down to the table with the rest of the family, to not even acknowledge anything or say, “Wow, you're great,” but just as if everyone had expected it. And there were a couple of other interventions. One I really liked was helping him step into the role of the grandfather. I think there was a 2-year-old in the family, and when he started taking on that role, and again, like you were saying, building those mental, emotional, and physical muscles, that created a lot of change. And it’s such a nice example of how you really stepped into your client’s worldview, both on a cultural level and through her own experiences, like her exercising, and how you used that perspective to shape language that resonated with her. And again, like you’re saying, that sense of feeling understood and activating those strengths.
Terry Soo-Hoo, Ph.D. (33:57):
Yeah. So to add to that the cultural component, she has seen another therapist, and the other therapist basically said, "you have to separate from your father, you're over involved with the father, you cannot be that responsible for your father." And she was basically saying, but in my culture, that's my job. My job is to take care of my father. If I don't do it, who's going to do it? It's going to be my responsibility. When I teach the multicultural class at the university, I talk about collectivist cultures. In a collectivist culture, there's a tremendous sense of obligation and responsibility. You don't turn your back on your family, no matter what it is. No matter what's going on, you have to be there. You have to be the responsible person even if it sacrifices your own needs. Even if it interferes with your own life, you have to do it. So what we are basically saying to her is, no you don't turn your back on your father. You just have to help him in a different way. You just have to help him in a more effective way. And that made much more sense to her. She's saying, "Thank you. Thank you. Now I feel like I'm really helping."
Keith Sutton, Psy.D. (35:22):
Oh, yes. I remember that from the article. You said we need to help in a more effective, efficient way, rather than the other therapist suggesting that you need to stop helping.
Terry Soo-Hoo, Ph.D. (35:32):
Yeah. So the other thing you mentioned that I really want to hone in on is the principle of changing roles. Again, it’s a family systems idea: because he is playing the incompetent role, the more competent she becomes, the less competent he seems. But how do you get people to change roles? You need to motivate them in a way that creates pleasurable, rewarding experiences. So what are the rewarding experiences? His 2‑year‑old granddaughter. And the family system had basically been fearful of him being around her. So we created a safe environment for him to step into that satisfying, rewarding role --where he started to feel more competent, more capable, and more able to be present for the little girl, the granddaughter. And over and over again, we find that this plays a huge role in changing the so‑called identified patient from the “incompetent” one, someone perceived as having something wrong with them, to a competent, positive person who can contribute.
Keith Sutton, Psy.D. (37:00):
Yeah and especially too, taking somebody out of their role is very hard, but giving them a new role that's more rewarding and also has meaning will oftentimes work a little better. Now, what can you tell me about your model that you have been working on about clients and culture, the model that you teach? What do you call it again?
Terry Soo-Hoo, Ph.D. (37:27):
Well, I actually have gone through different names, but the latest name I call it is strengths-based, culturally informed integrative therapy.
Keith Sutton, Psy.D. (37:38):
Great.
Terry Soo-Hoo, Ph.D. (37:39):
And so all of that has significance --strength‑based work, which we talked about as being really important in my model to activate client strengths. And then culture: we talked about the importance of cultural work and how clients need culture integrated into the process. also talked about the fact that it's an integrative model. Even though I have a core set of ideas, mainly what I described as the MRI model and strategic therapy, I’ve integrated elements from solution‑focused work, family systems, narrative therapy, and many other models. I'm not above using cognitive‑behavioral strategies or even Gestalt techniques when they fit. I'm pretty flexible. But again, when I teach therapy, I make a distinction between being eclectic and being an integrationist. An eclectic therapist just pulls from anywhere “whatever works" but it often lacks coherence, clarity, and focus. It doesn’t feel as clear in terms of direction or integration. An integrationist, on the other hand, carefully picks and chooses techniques, theories, and methods that fit well together. There’s a sense of coherence, a sense of direction, and a sense of clarity about what you’re doing.
Keith Sutton, Psy.D. (39:20):
And oftentimes those different techniques can build on each other more in a strategic direction, versus what you were describing as one week trying this, another week trying that, or saying, “I'm stuck here, let me try this now.” So tell me a little bit about how you work with students, you're doing a lot of great teaching, how do you help them become more culturally informed? You know there's the emic culture which is the macro culture, and then there's the micro of the person's experience in their own family. Then the third element is the therapist culture, privilege, and their blind spots. All of those pieces are essential in teaching. So tell me a little bit more, do you have approaches or ways you think about helping clinicians understand these aspects of culture and become more culturally informed?
Terry Soo-Hoo, Ph.D. (40:34):
This is a very challenging area in our work in terms of therapists and trainers of therapists because it's not easy to do exactly all the things you've talked about. So there are a couple of basic things that I focus on that conveys two main ideas that makes a good therapist: adaptability and flexibility. Ultimately, the challenge is to be able to adapt the method to fit the client rather than force the client to adapt to your method. That's not easy because we tend to have sort of narrow views of thinking "this is what needs to happen" and "this is what should happen" and "this is how I'm going to make it happen." But ultimately it's how to be creative, how to be expansive, and how to open up all these different possibilities and ideas. And then the other part is to be aware of your own unconscious bias. When I teach a multicultural class, a huge factor in our work is unconscious bias. The goal isn't necessarily to eliminate bias because that's not possible. You can never be totally bias free, there's no such thing as blank slate. The goal always is to be aware of your biases and to really be aware of your own values, your own ways of seeing the world, your own concepts of what is a relationship, what's love, what's caring, what all these kinds of things were culturally determined. Then decide, am I able to put aside them when I need to? Can I put aside these values, ideas when I need to, but then when do I need to assert my values? Because you also need to do that. The simple situations are violence and abuse. In those cases, I need to assert my values. It is not acceptable to abuse your spouse and it is not acceptable to hit your child or hurt your child.
Keith Sutton, Psy.D. (42:50):
Yeah.
Terry Soo-Hoo, Ph.D. (42:51):
You need to assert that bias and that value, but it needs to be conscious, not unconscious. And have clarity about it -- that's what we have to work on. So how do you develop that clarity about when to put aside and when to assert?
Keith Sutton, Psy.D. (43:11):
Oftentimes I will even bring it to my clients and when I think that things should be going one way, but they're not, sometimes it's a moment for me to actually step back and say, "I'm thinking if it was going this way, well, it would go like this." Particularly one couple I was working with, she was from Hong Kong and he had grown up on mainland China, and they had different experience. She was saying "I feel like you don't love me." And in my head, I was like, sir, you love her. You know, like trying to telepathically have him share that. And then I said "I would imagine you might say you love her, what's coming up?" And he said "Well, in my family being quiet is a way of showing our remorse and our support and our sadness. If someone said I love you, it would be like, oh my gosh, is somebody dying? Like, what's going on here? There's something weird happening." Again, her micro and macro cultures and his micro and macro cultures were really bumping up against each other, even though they were both Chinese. Looking at those pieces, I learned a lot just by checking out an assumption with my client.
Terry Soo-Hoo, Ph.D. (44:30):
I mean men and women have a different way of communicating sometimes.
Keith Sutton, Psy.D. (44:34):
Yeah. Totally.
Terry Soo-Hoo, Ph.D. (44:35):
Sometimes it's about culture, sometimes gender differences.
Terry Soo-Hoo, Ph.D. (44:38):
I'll give you another fascinating example, similar to what we're talking about, I worked with one couple where, the therapist --we do this one way mirror thing-- the therapist in the room started saying, "it sounds like your husband really needs a lot of reinforcement every time something happens. So why don't you just say, thank you honey, I really appreciate that, and so on." And she says "in my culture, we don't say that. We say that to strangers, we don't say that to our own family members. That's not appropriate." So then I asked the interns in our training group, so what's the alternative? You know, how does one person reward or reinforce positive behavior? And they all go blank. I said, be creative, think. What are all these different things? In my experience working with couples, they've come up with all kinds of things because this is a common pattern of couples therapy -- how to bring back the positive communication and reinforce positive behavior for each other. That's a common focus in couples therapy. And students blank out. I'll tell you all the things that we come up with. Things like, how about using food? Since it's a major cultural thing in some countries. How about smiling? And we've had one couple say, well we just smile at each other. We've had one couple actually come up with winking. Everybody starts laughing and they said they never thought about it like that. That's the creativity.
Keith Sutton, Psy.D. (46:41):
Yes. Yes.
Terry Soo-Hoo, Ph.D. (46:42):
That's thinking out of the box, and it's hard to teach. But that's what successful therapists are. Creative.
Keith Sutton, Psy.D. (46:54):
Well and coming together with the clients --I know with that client I was mentioning, for him the fact that he needed to say "I love you" was a failure, that she didn't know it. But then they were able to have a conversation around it with each other and with myself creatively figuring out what is the way to express that care or love that felt appropriate within the culture or in this situation. Kind of flexing within that and so on. But again, knowing the origins and not pathologizing it is so important in understanding that dynamic to then be able to create some change.
Terry Soo-Hoo, Ph.D. (47:36):
Yeah but you trigger another thought that I have related to something like this. So when we work with couples, another basic principle is if they're going to do something, they need to do it in a safe way. If saying "I love you" feels really weird and awkward and unsafe, then that's not going to work. So then what we do is --this is the classic MRI model, or actually solution-focused-- people do this a little bit too, and that is do something surprising, but don't tell her what it is. And then you act surprised when she's surprised. What happens is that not only creates a sense of safety, but it creates a sense of mystery and excitement and laughter.
Keith Sutton, Psy.D. (48:31):
Yes.
Terry Soo-Hoo, Ph.D. (48:31):
If you start laughing, that's the idea of bringing back that sense of joy and freedom and laughter.
Keith Sutton, Psy.D. (48:39):
Yeah and I think too that oftentimes playfulness and creativity go hand in hand. I forget, sometimes would you also tell the other client that the other person is going to surprise them, but they won't know or they won't be told, they'll just kind of see?
Terry Soo-Hoo, Ph.D. (49:00):
There are many versions of this.
Keith Sutton, Psy.D. (49:01):
Yeah so one is heightening their attention and keeping an eye out for it while the other one's looking for these opportunities and then bringing it back helps again, creating that shift in the stuck dynamic.
Terry Soo-Hoo, Ph.D. (49:18):
Yeah. So another version is to take that one step further and that is what would you do in response when he does something surprising? What are you going to do in response that's also shocking or surprising so that creates that sense of excitement?
Keith Sutton, Psy.D. (49:37):
Do you remember any examples of that at all?
Terry Soo-Hoo, Ph.D. (49:40):
Well the simple ones actually shock me. One couple presented in such a conservative way, but she pulled up her blouse and showed her breasts. It's something I would've never guessed.
Keith Sutton, Psy.D. (50:05):
Yeah, you probably can't prescribe that in therapy and say "oh, you should do this" but yes again creating that openness for the chance for creativity it sounds like she tried something different.
Terry Soo-Hoo, Ph.D. (50:16):
That's right. Every time I tell these stories, people say, "you make it seem like therapy can be fun." I say yes. Not all the time, but yeah. Sometimes it can be fun.
Keith Sutton, Psy.D. (50:30):
Definitely. Well, it's so wonderful to hear about the work that you've been doing and it's sad, unfortunately, that the MRI is closed now. So many great ideas and folks doing lots of different work came out of there. I'm glad that you're continuing on the work that you're doing and the writing and the teaching because I think it's really important to be passing on to that next generation. Oftentimes, they're not learning these in grad school when they're just learning CBT or psychoanalytic or so on. Because the brief and strategic is also really about being with the client and being able to figure out those different ways to change the patterns but it's grounded in joining with them. Both on an individual level as well as looking at the cultural aspects to join with them.
Terry Soo-Hoo, Ph.D. (51:29):
Yeah I just want to reinforce that idea that brilliant interventions are great, but they can only work when there is that sense of connection with the client. It is important to do both the interventions but to really have that relationship.
Keith Sutton, Psy.D. (51:47):
Definitely. Yeah, well thank you so much for your time today. I really appreciate it.
Terry Soo-Hoo, Ph.D. (51:57):
I enjoyed it. So certainly invite me again.
Keith Sutton, Psy.D. (52:00):
Yes, definitely will do. Take care.
Terry Soo-Hoo, Ph.D. (52:03):
Okay, great. Thank you for the opportunity.
Keith Sutton, Psy.D. (52:05):
Sure. Bye-bye.
Terry Soo-Hoo, Ph.D. (52:06):
Talk again. Bye-bye.
Keith Sutton, Psy.D. (52:09):
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Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy at the Institute for the Advancement of Psychotherapy. We provide training in evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in evidence-based approach with our Lifespan Centers, center for Children and Center for Adolescents, where all the therapists are working systemically. Our Center for Couples, where all the therapists are using emotionally focused couples therapy and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma, and our center for ADHD and oppositional and Conduct Disorder clinic, where we're integrating those four approaches. In the Institute we have our licensed experienced therapists, and for those in financial need, we have an associated nonprofit Bay Area Community Counseling where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training and one-way mirror trainings in family systems. To learn more about trainings, treatment and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501 C3 nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (02:20):
Today I'll be interviewing Terry Soo-Hoo PhD, who is currently a professor at the California State University, East Bay in the Marriage and Family Therapy Program, and he was the clinical director of the Mental Research Institute in Palo Alto. Terry completed his PhD in clinical psychology at the University of California Berkeley, and he's board certified in family and couples psychology. Prior to university teaching, he devoted over 20 years as a psychologist in community mental health services in San Francisco, working with diverse range of people with many different psychological problems. These publications include topics on multicultural issues and psychotherapy and consultation, brief therapy and couples therapy. He has special interest in the area of innovative, culturally relevant approaches to psychotherapy, and he has provided extensive presentations, trainings, supervision, and consultation on these topics to agencies and other professionals in many countries around the world. Let's listen to the interview.
Keith Sutton, Psy.D. (03:20):
Well, hi, Terry. Welcome.
Terry Soo-Hoo, Ph.D. (03:22):
Yes. Glad to be here. Thank you for inviting me.
Keith Sutton, Psy.D. (03:26):
Yeah. Thanks for coming on. So Terry, I know a little bit about your work and we had talked when you were down at the mental research Institute in Palo Alto. Recently we've been chatting about you maybe doing an event for the Association of Family Therapists in Northern California on your model for working with clients and in a cultural competency way. You'll have to tell me again how you term it, but first I would love to hear about your path to doing this kind of work and your evolution of thinking.
Terry Soo-Hoo, Ph.D. (04:04):
Sure. Yeah I go way back to the late 1970s, I started by finishing my master's degree in counseling in San Francisco State University and I started working in child family clinic in Chinatown and started to really try to apply what I was learning. I became very frustrated at the time because my main training at the time was psychoanalytic and psychodynamic theory and what we discovered is that it wasn't working well with the immigrant population. We were struggling with it. It was a very traditional, for children's play therapy, very psychoanalytic type of play therapy. Even though we had some successes, oftentimes they would take a long time. And for every successful case we had that took over a year or sometimes two years, there were a number of cases to drop out after a few sessions because they didn't want to stay in therapy for over a year or so. I started to get the feeling that maybe something else could be more effective in a shorter period of time. So that was sort of one of the experiences I had to shape my view of the work. The other major impact I had in that kind of work was one incident where I was talking to a Chinese mother, an immigrant mother, about her five-year-old son. My supervisor at the time, who was very traditional psychoanalytic, started instructing me to tell this mother that her son had an oedipal complex. And I was supposed to explain to this mother, and my Chinese wasn't that good at the time, that her son had this sexual attraction to you and wanted to get rid of his father in order to possess her more fully.
Terry Soo-Hoo, Ph.D. (06:35):
And I remember after I finished saying that, she looked at me like I was crazy. That had an impact on me, realizing this doesn't seem to be working well in this population. In retrospect you could say, well, maybe I could have done it more skillfully, maybe I could have presented it in a different way and stuff like that. But, my sense of it is that no matter how I presented it, the idea was not very acceptable. It seemed like it was fitting. It just didn't seem to fit her culture perspective. So I went to UC Berkeley to get my PhD thinking I would find the answer there, at the top school. Unfortunately, the first year I got more psychoanalytic training and it was very psychodynamic at the time. This time it was called ego psychology. But I still didn't feel very satisfied with what I was getting until I took a course called Strategic Therapy by this guy named Jim Coyne, who was teaching at MRI at the time. And I didn't know anything about it. I just liked the idea of strategies that work. So he said something very profound and it's really stuck with me. He said that most people who come to therapy are not sick or pathological. But most people who come to therapy are stuck not finding the right solutions to their problems. So the goal of therapy wasn't to cure sickness or pathology. The goal of therapy was to help people get unstuck and that made so much sense to me.
Terry Soo-Hoo, Ph.D. (08:39):
Then I started to explore the idea of how people got stuck really was related to their cultural context. Therefore, in order to get help people get unstuck, we have to work within their cultural context, so the solutions had to fit their culture. I went to MRI to do an intensive training. I worked with the main founders, Paul Bosnick and John Wheatland Fish, and did an intensive one year training there. After I finished, I started to apply this method everywhere I worked. For 20 years, I've worked in community mental health and inpatient outpatient residential treatment, children, families, the entire gamut of the diversity of different cultures, different races. Everywhere I went, I started to apply this approach with some modifications. I started adding my own modifications to it. In fact, it was so successful that I started a consultation group. Clinicians from all over the city and in the county of San Francisco came and brought their most difficult cases. I would offer suggestions and ideas, and it was extremely successful and people found it very helpful.That lasted for a few years. Then I left community mental health and I started teaching at the university level. I taught at four different universities and I'm now currently at Cal State East Bay where I continue to modify and adapt this method.
Keith Sutton, Psy.D. (10:31):
Great. And particularly I'm always interested in this because I did some trainings with Karen Schlanger with the brief team at MRI. Dick Fish came in to say hi, but he wasn't there much anymore and then I worked with the strategic team with Eileen Barbaro for almost a year. I've always wondered about strategic and this group at MRI. Could you talk a little bit about the difference between the brief therapy model and the Jay Haley strategic family therapy model?
Terry Soo-Hoo, Ph.D. (11:13):
Yeah. First of all, I think that the strength of the strategic model, including the MRI model, is that it has very skillful effective techniques and interventions. So in my perspective, that's where the emphasis has been. The emphasis has been these brilliant interventions and these strategies and ideas. In my years of experience at MRI, and after I started working in the field, I started to focus on two areas that I thought really did not get enough attention.The fascinating thing is that the successful therapies have these elements in common that people did not talk about. These two elements are, one, there's not enough focus on the humanistic elements of the relationship. That the basic fundamental processes of how the relationships facilitate people's abilities to change and to really benefit from the therapy. So of course, Scott Miller talks about how 30% of the outcome is really connected to the therapeutic relationship, and there wasn't sufficient focus on how any interventions has to be built upon a positive relationship first to be effective. So I started to focus much more on that, my writing, my training, and so on. Well, actually, there are three elements. The second element was not enough conversations about culture. MRI actually saw a lot of different cultures, particularly Spanish speaking, and we did a lot of therapy with LA Latino clients through translators and different ways of communicating.
Terry Soo-Hoo, Ph.D. (13:37):
But then the very few people actually wrote about it, very, people actually talked about the importance of culture. And what I say is you have to enter the client's world, and every client brings to therapy a unique world. Just because you happen to be a similar cultural ethnic background doesn't mean you live in the same world as the client. So we're not just talking about culture either. We're talking about the uniquenesses of somebody's world. Somebody's worldview, somebody's experiences, somebody's value systems and perspectives. There wasn't enough discussion about that. But over and over again, the research is very clear that successful therapies are successful because the therapist is able to work within the clients in the world. And the unsuccessful therapies are partly, many times the results of not being able to work within the clients' unique world.
Terry Soo-Hoo, Ph.D. (14:44):
And so I started to focus a lot more on that in my training and in my writing and I brought that to MRI. The third element that I really felt needed more attention was, again, MRI did it, but did not talk about it enough, and that was to activate the client's strengths. When I do my trainings, I talk about Scott Miller and the four different elements that he says account for treatment outcome success. Where the first element --30% of the outcome-- is attributed to the relationship. Now, only 15% was actually attributed to technique and theory. I think that it's really probably more, but it's the limitation of the methodology. It's very difficult to compare 10 different theories and 10 different approaches and see which one works better. So it hasn't been done. Scott Miller basically says, across all therapies, all therapies work. It has more to do with the skills of the therapist. Unfortunately, we still need more research to clarify what techniques work better. But a huge 40% of the outcome is due to client factors, which is basically two things that it's going to break down to. One is the strengths and resources that the client bring to therapy and two is client motivation. So that makes sense that the more strengths and resources the client has, the more they can benefit from therapy. And two, the more motivated they are, the more likely they'll also benefit from therapy. So the fourth factor, 15% of the outcome is due to placebo effect. I just interpret that as the belief in the therapy and the therapist.
Keith Sutton, Psy.D. (17:00):
That makes perfect sense.
Terry Soo-Hoo, Ph.D. (17:01):
Yeah. The more you believe that the therapy will help, the more you believe the therapist can help you, the more likely you'll listen and take what the therapist says and implement it. The reason I'm presenting this is because in my view, if you activate the client's strengths, all four factors improve. If you activate the client's strengths, the relationship increases, and the techniques and interventions become much more effective. Obviously the resources and strengths the client has enhances the client's motivation. And four, it really creates that sense of belief. When the therapist activates the client's strengths, the client's much more likely to say, "this therapist can help me and I can really follow what this therapist is saying."
Keith Sutton, Psy.D. (18:12):
It sounds like grounded in what you were saying earlier, that looking at seeing the client as stuck rather than a pathology or sick, also assumes that the client is stuck, but has the resources and might just need to get a little unstuck. You don't need to rebuild the whole car. You might help them jumpstart it a little bit or get going in a different direction. As I'm hearing you talking, I'm thinking about when we see clients' strengths, oftentimes they feel seen. We see the person in there or their strengths or where they want to be or who they want to be, and seeing that change already before they've even begun it. Connected to that hope, that's going to strengthen the alliance if the person feels seen and heard then that alliance, like you're saying, is the basis of everything, motivation, and the working relationship -- all those aspects.
Terry Soo-Hoo, Ph.D. (19:18):
Yeah, absolutely. But I also want to add another thing too, in that when we work with students or trainees or interns, what oftentimes they discover is that for many clients, if you only talk about their strengths, then they bounce over to the other side. And then we have to sort of clarify this particular point.
Keith Sutton, Psy.D. (19:40):
Yes, yes.
Terry Soo-Hoo, Ph.D. (19:41):
You know, then they'll say, "but, but, but" and so what we tell trainees and interns is that you really need to help the client to appreciate and acknowledge both sides. It's the struggle that we are helping them with. On the one side, there is this sense of so much capacity, so much potential, so much intelligence and history of successes in certain areas of their lives. And they have the capacity and the ability to really cope and deal with things. But on the other hand, there's a tremendous sense of fear, anxiety, insecurity, just being overwhelmed with crises and things like that. What we say is we need to acknowledge both. We need to help them with the struggle of how to activate the strong part of them so they can cope more effectively with the fear and the anxiety and the insecurities.
Keith Sutton, Psy.D. (20:40):
Definitely. Yeah and it makes me think of motivational interviewing where the assumption is that everyone has ambivalence. There's a part of them that wants change, there's a part of them that wants to keep sustaining where they're at, and really helping to navigate those pieces.
Terry Soo-Hoo, Ph.D. (20:59):
Without getting myself into trouble a little bit, motivational interview has so many connections to MRI and some of the strategic ideas. I don't necessarily want to take away from their work, but there's a connection.
Keith Sutton, Psy.D. (21:13):
Sure. So much was influenced by MRI and I actually want to go back, if it's okay, to that question about the brief therapy team. The way I differentiated was that the MRI brief therapy team focused on that 180 degree change, that the attempted solution has become the problem, then the family or the client is getting stuck. Helping them to do a 180 degree change to become unstuck and create some kind of change in the system, ideally, is going to help with some movement versus the more strategic family therapy where there's a lot more focus on the hierarchy and the more paradoxical interventions, which again, I don't know if that's also with the brief team. The brief team always felt to me like they distilled it down to this element. Strategic had a lot of different pieces going on. But I'd love to get your thoughts because MRI was this place where both were going on. I don't know about when you were there, if they were both going on having the two different mirrors or if that had been combined.
Terry Soo-Hoo, Ph.D. (22:31):
Yeah, I think your observations are pretty accurate that Jay Haley was at MRI, then he left and developed his ideas further. My sense of it is that the Jay Haley version really does focus a lot on the paradoxical disruptions of the pattern. There is that sense of looking to disrupt the power hierarchy and the relationship. He focuses a lot on the function: the symptoms of a function, the disruption of a function.
Keith Sutton, Psy.D. (23:19):
May not be able to go directly at it to you. So that's where those paradoxes come in.
Terry Soo-Hoo, Ph.D. (23:23):
Yeah, that's right. And the MRI model really has more to do with trying to focus on what's not working. The simple view is that the more you do something that doesn't work, the more the situation is perpetuated and the problem continues and it aggravates it and expands on it. So they're much more into second order change, where it disrupts those kinds of interaction patterns that are not working. It's escalating the pattern. So there's a shift in focus. Some of the strategies sometimes overlap. I think that both methods do have paradoxical intention, but the way I teach it in MRI is that unfortunately, people who only have superficial knowledge of strategic therapy or MRI tie it too much to the concept of paradox. In my view, paradox is just a technique. It doesn't define the theory. The theory really is what's not working.
Keith Sutton, Psy.D. (24:40):
Yes.
Terry Soo-Hoo, Ph.D. (24:41):
Because the more you do something that doesn't work, the worse the problem gets. So the theory is how do you stop those interaction patterns that are not working. Then how do you replace them with different behaviors, different strategies that breaks that pattern, and then initiates new solutions, new patterns that work better. So paradox is just one way to do this. I'm not sure if that's even my preferred way. My preferred way has more to do with reframing and changing. The perception and meaning, narrative therapy, causes rewriting your story, changing your narrative. But that's an important aspect of how we stop the interaction patterns that don't work well. You help the client see the situation a different way, which leads them to a different pattern.
Keith Sutton, Psy.D. (25:38):
Yes. Well I'm thinking about how I was reading over one of your articles on single session work, and there was an example that you gave of a Vietnamese woman that you had worked with. I don't know if you would like to, I thought you really went with her worldview and her perspective and built on that with an intervention that ended up being very successful. Can you speak to that at all?
Terry Soo-Hoo, Ph.D. (26:10):
Yeah actually I've read so many articles, you need to give me a better idea.
Keith Sutton, Psy.D. (26:16):
Sure. I can give you more. The father was sick and the daughter was taking care of the father. She was bringing food and so on, and he had experienced trauma from Vietnam. They had moved when she was young, and she had gone to another therapist who said that she needed to individuate and become more independent and that really felt bad to her because she felt like her father would die if she was not taking care of him. There was the mother and I think two or three other kids and telling her to do less, even though there was sort of an enabling part that was going on, that would've of course not worked. But instead you actually encourage her to do more, but in a different direction.
Terry Soo-Hoo, Ph.D. (27:01):
Yeah this is a good example of a number of factors that are important to pay attention to in these types of cases. Culture certainly plays a huge role, but this interaction pattern is quite common. So let's throw out one thing at a time. Basically, the interaction pattern is that the more the daughter took care of the father, the more incompetent the father was, and that is a common pattern. It is a very common pattern in family systems theory. Basically, if you have a very powerful person who plays the competent role, Salvador Minuchin calls this complementarianism, meaning that the flip side is you have an incompetent person and that then sort of balances out. So in order for that system to change, the competent person has to become less competent by taking a step back and allowing the less competent person to step up. This is the common dynamic in many of these kinds of relationship issues, but the cultural element is you can't tell people that. If you could just tell people to stop it then therapy would be easy. So the challenge of therapy is to figure out how you help people change that interaction pattern if you want to see a family systems view of the family structure. You have to do it within something that fits the client's culture that makes sense to the client. And again, it's not just culture, it's their world view, their view of their role. And in this particular case, she's the number one daughter. So therefore her role is the caretaker.
Terry Soo-Hoo, Ph.D. (29:01):
"I'm responsible, I have to do this. If I don't do it, he is going to die. The world's going to collapse." Yes, those kinds of feelings. And the mother has basically abdicated her role because she's given up. “I'm just going to take care of myself, and I just have to take care of the other children.” So if she's left being the sole caretaker, it's very hard to tell her to back off. It's very difficult. So our challenge in our work is: how do you help her see the situation differently and allow her to view the solutions differently? So what we explored with her is what the father really needs. What helped her was the idea that she went to the gym, lifted weights, and did other activities like that. It had personal relevance to her in her world. So I asked: have you ever thought about muscle --how, in order to maintain muscle tone, you need to exercise the muscles? Emotional muscles are the same. Mental muscles are the same. Physical muscles are the same. You need to exercise them because if you don't exercise, they atrophy and deteriorate right away. So he says, “My concern is that your dad is experiencing atrophy emotionally, mentally, physically, and so on.” She says, “Yes, I'm concerned about that.” He replies, “Great, you're concerned. So what do you think we need to do?”
Terry Soo-Hoo, Ph.D. (30:57):
And then I ask her, "have you ever thought about the idea that when you're at the gym, you can ask somebody else to lift your weights for you? And she laughed and she says, "No, that's silly." So I said, "Well, I wonder if you see a parallel of what's happening with your father, that basically you're lifting all the weight. Everybody else is lifting weight. And what happens to him? He's atrophied. So what do you think he means?" She says, "Well, I think he needs to lift his own weight." I said "How do we get him to do that?" Now there is what we call a shift in meaning perceptions about what the issue is. What she would do is she would take food to him three times a day and didn't even let him walk down the stairs in order to eat. And so we said, "let's start small. You know what, if you were to cook meals and make sure that he smelled all the food and open all the doors and just waited and see how long it would take." Well, she wondered what if he never ate? Well, research says one or two days is probably okay. If he doesn't eat for three days, I would be worried. But it didn't take long, as soon as he smelled the food and he realized people weren't walking up to feed him, he went downstairs and started to eat. That was just the first step. Then we built on that, had him do more and more, and then she would do less and less.
Keith Sutton, Psy.D. (32:48):
Yeah, and I think when you went into the writing, you were saying something especially aromatic that smelled so good he wouldn’t be able to resist coming down. And when Lenny did come down to the table with the rest of the family, to not even acknowledge anything or say, “Wow, you're great,” but just as if everyone had expected it. And there were a couple of other interventions. One I really liked was helping him step into the role of the grandfather. I think there was a 2-year-old in the family, and when he started taking on that role, and again, like you were saying, building those mental, emotional, and physical muscles, that created a lot of change. And it’s such a nice example of how you really stepped into your client’s worldview, both on a cultural level and through her own experiences, like her exercising, and how you used that perspective to shape language that resonated with her. And again, like you’re saying, that sense of feeling understood and activating those strengths.
Terry Soo-Hoo, Ph.D. (33:57):
Yeah. So to add to that the cultural component, she has seen another therapist, and the other therapist basically said, "you have to separate from your father, you're over involved with the father, you cannot be that responsible for your father." And she was basically saying, but in my culture, that's my job. My job is to take care of my father. If I don't do it, who's going to do it? It's going to be my responsibility. When I teach the multicultural class at the university, I talk about collectivist cultures. In a collectivist culture, there's a tremendous sense of obligation and responsibility. You don't turn your back on your family, no matter what it is. No matter what's going on, you have to be there. You have to be the responsible person even if it sacrifices your own needs. Even if it interferes with your own life, you have to do it. So what we are basically saying to her is, no you don't turn your back on your father. You just have to help him in a different way. You just have to help him in a more effective way. And that made much more sense to her. She's saying, "Thank you. Thank you. Now I feel like I'm really helping."
Keith Sutton, Psy.D. (35:22):
Oh, yes. I remember that from the article. You said we need to help in a more effective, efficient way, rather than the other therapist suggesting that you need to stop helping.
Terry Soo-Hoo, Ph.D. (35:32):
Yeah. So the other thing you mentioned that I really want to hone in on is the principle of changing roles. Again, it’s a family systems idea: because he is playing the incompetent role, the more competent she becomes, the less competent he seems. But how do you get people to change roles? You need to motivate them in a way that creates pleasurable, rewarding experiences. So what are the rewarding experiences? His 2‑year‑old granddaughter. And the family system had basically been fearful of him being around her. So we created a safe environment for him to step into that satisfying, rewarding role --where he started to feel more competent, more capable, and more able to be present for the little girl, the granddaughter. And over and over again, we find that this plays a huge role in changing the so‑called identified patient from the “incompetent” one, someone perceived as having something wrong with them, to a competent, positive person who can contribute.
Keith Sutton, Psy.D. (37:00):
Yeah and especially too, taking somebody out of their role is very hard, but giving them a new role that's more rewarding and also has meaning will oftentimes work a little better. Now, what can you tell me about your model that you have been working on about clients and culture, the model that you teach? What do you call it again?
Terry Soo-Hoo, Ph.D. (37:27):
Well, I actually have gone through different names, but the latest name I call it is strengths-based, culturally informed integrative therapy.
Keith Sutton, Psy.D. (37:38):
Great.
Terry Soo-Hoo, Ph.D. (37:39):
And so all of that has significance --strength‑based work, which we talked about as being really important in my model to activate client strengths. And then culture: we talked about the importance of cultural work and how clients need culture integrated into the process. also talked about the fact that it's an integrative model. Even though I have a core set of ideas, mainly what I described as the MRI model and strategic therapy, I’ve integrated elements from solution‑focused work, family systems, narrative therapy, and many other models. I'm not above using cognitive‑behavioral strategies or even Gestalt techniques when they fit. I'm pretty flexible. But again, when I teach therapy, I make a distinction between being eclectic and being an integrationist. An eclectic therapist just pulls from anywhere “whatever works" but it often lacks coherence, clarity, and focus. It doesn’t feel as clear in terms of direction or integration. An integrationist, on the other hand, carefully picks and chooses techniques, theories, and methods that fit well together. There’s a sense of coherence, a sense of direction, and a sense of clarity about what you’re doing.
Keith Sutton, Psy.D. (39:20):
And oftentimes those different techniques can build on each other more in a strategic direction, versus what you were describing as one week trying this, another week trying that, or saying, “I'm stuck here, let me try this now.” So tell me a little bit about how you work with students, you're doing a lot of great teaching, how do you help them become more culturally informed? You know there's the emic culture which is the macro culture, and then there's the micro of the person's experience in their own family. Then the third element is the therapist culture, privilege, and their blind spots. All of those pieces are essential in teaching. So tell me a little bit more, do you have approaches or ways you think about helping clinicians understand these aspects of culture and become more culturally informed?
Terry Soo-Hoo, Ph.D. (40:34):
This is a very challenging area in our work in terms of therapists and trainers of therapists because it's not easy to do exactly all the things you've talked about. So there are a couple of basic things that I focus on that conveys two main ideas that makes a good therapist: adaptability and flexibility. Ultimately, the challenge is to be able to adapt the method to fit the client rather than force the client to adapt to your method. That's not easy because we tend to have sort of narrow views of thinking "this is what needs to happen" and "this is what should happen" and "this is how I'm going to make it happen." But ultimately it's how to be creative, how to be expansive, and how to open up all these different possibilities and ideas. And then the other part is to be aware of your own unconscious bias. When I teach a multicultural class, a huge factor in our work is unconscious bias. The goal isn't necessarily to eliminate bias because that's not possible. You can never be totally bias free, there's no such thing as blank slate. The goal always is to be aware of your biases and to really be aware of your own values, your own ways of seeing the world, your own concepts of what is a relationship, what's love, what's caring, what all these kinds of things were culturally determined. Then decide, am I able to put aside them when I need to? Can I put aside these values, ideas when I need to, but then when do I need to assert my values? Because you also need to do that. The simple situations are violence and abuse. In those cases, I need to assert my values. It is not acceptable to abuse your spouse and it is not acceptable to hit your child or hurt your child.
Keith Sutton, Psy.D. (42:50):
Yeah.
Terry Soo-Hoo, Ph.D. (42:51):
You need to assert that bias and that value, but it needs to be conscious, not unconscious. And have clarity about it -- that's what we have to work on. So how do you develop that clarity about when to put aside and when to assert?
Keith Sutton, Psy.D. (43:11):
Oftentimes I will even bring it to my clients and when I think that things should be going one way, but they're not, sometimes it's a moment for me to actually step back and say, "I'm thinking if it was going this way, well, it would go like this." Particularly one couple I was working with, she was from Hong Kong and he had grown up on mainland China, and they had different experience. She was saying "I feel like you don't love me." And in my head, I was like, sir, you love her. You know, like trying to telepathically have him share that. And then I said "I would imagine you might say you love her, what's coming up?" And he said "Well, in my family being quiet is a way of showing our remorse and our support and our sadness. If someone said I love you, it would be like, oh my gosh, is somebody dying? Like, what's going on here? There's something weird happening." Again, her micro and macro cultures and his micro and macro cultures were really bumping up against each other, even though they were both Chinese. Looking at those pieces, I learned a lot just by checking out an assumption with my client.
Terry Soo-Hoo, Ph.D. (44:30):
I mean men and women have a different way of communicating sometimes.
Keith Sutton, Psy.D. (44:34):
Yeah. Totally.
Terry Soo-Hoo, Ph.D. (44:35):
Sometimes it's about culture, sometimes gender differences.
Terry Soo-Hoo, Ph.D. (44:38):
I'll give you another fascinating example, similar to what we're talking about, I worked with one couple where, the therapist --we do this one way mirror thing-- the therapist in the room started saying, "it sounds like your husband really needs a lot of reinforcement every time something happens. So why don't you just say, thank you honey, I really appreciate that, and so on." And she says "in my culture, we don't say that. We say that to strangers, we don't say that to our own family members. That's not appropriate." So then I asked the interns in our training group, so what's the alternative? You know, how does one person reward or reinforce positive behavior? And they all go blank. I said, be creative, think. What are all these different things? In my experience working with couples, they've come up with all kinds of things because this is a common pattern of couples therapy -- how to bring back the positive communication and reinforce positive behavior for each other. That's a common focus in couples therapy. And students blank out. I'll tell you all the things that we come up with. Things like, how about using food? Since it's a major cultural thing in some countries. How about smiling? And we've had one couple say, well we just smile at each other. We've had one couple actually come up with winking. Everybody starts laughing and they said they never thought about it like that. That's the creativity.
Keith Sutton, Psy.D. (46:41):
Yes. Yes.
Terry Soo-Hoo, Ph.D. (46:42):
That's thinking out of the box, and it's hard to teach. But that's what successful therapists are. Creative.
Keith Sutton, Psy.D. (46:54):
Well and coming together with the clients --I know with that client I was mentioning, for him the fact that he needed to say "I love you" was a failure, that she didn't know it. But then they were able to have a conversation around it with each other and with myself creatively figuring out what is the way to express that care or love that felt appropriate within the culture or in this situation. Kind of flexing within that and so on. But again, knowing the origins and not pathologizing it is so important in understanding that dynamic to then be able to create some change.
Terry Soo-Hoo, Ph.D. (47:36):
Yeah but you trigger another thought that I have related to something like this. So when we work with couples, another basic principle is if they're going to do something, they need to do it in a safe way. If saying "I love you" feels really weird and awkward and unsafe, then that's not going to work. So then what we do is --this is the classic MRI model, or actually solution-focused-- people do this a little bit too, and that is do something surprising, but don't tell her what it is. And then you act surprised when she's surprised. What happens is that not only creates a sense of safety, but it creates a sense of mystery and excitement and laughter.
Keith Sutton, Psy.D. (48:31):
Yes.
Terry Soo-Hoo, Ph.D. (48:31):
If you start laughing, that's the idea of bringing back that sense of joy and freedom and laughter.
Keith Sutton, Psy.D. (48:39):
Yeah and I think too that oftentimes playfulness and creativity go hand in hand. I forget, sometimes would you also tell the other client that the other person is going to surprise them, but they won't know or they won't be told, they'll just kind of see?
Terry Soo-Hoo, Ph.D. (49:00):
There are many versions of this.
Keith Sutton, Psy.D. (49:01):
Yeah so one is heightening their attention and keeping an eye out for it while the other one's looking for these opportunities and then bringing it back helps again, creating that shift in the stuck dynamic.
Terry Soo-Hoo, Ph.D. (49:18):
Yeah. So another version is to take that one step further and that is what would you do in response when he does something surprising? What are you going to do in response that's also shocking or surprising so that creates that sense of excitement?
Keith Sutton, Psy.D. (49:37):
Do you remember any examples of that at all?
Terry Soo-Hoo, Ph.D. (49:40):
Well the simple ones actually shock me. One couple presented in such a conservative way, but she pulled up her blouse and showed her breasts. It's something I would've never guessed.
Keith Sutton, Psy.D. (50:05):
Yeah, you probably can't prescribe that in therapy and say "oh, you should do this" but yes again creating that openness for the chance for creativity it sounds like she tried something different.
Terry Soo-Hoo, Ph.D. (50:16):
That's right. Every time I tell these stories, people say, "you make it seem like therapy can be fun." I say yes. Not all the time, but yeah. Sometimes it can be fun.
Keith Sutton, Psy.D. (50:30):
Definitely. Well, it's so wonderful to hear about the work that you've been doing and it's sad, unfortunately, that the MRI is closed now. So many great ideas and folks doing lots of different work came out of there. I'm glad that you're continuing on the work that you're doing and the writing and the teaching because I think it's really important to be passing on to that next generation. Oftentimes, they're not learning these in grad school when they're just learning CBT or psychoanalytic or so on. Because the brief and strategic is also really about being with the client and being able to figure out those different ways to change the patterns but it's grounded in joining with them. Both on an individual level as well as looking at the cultural aspects to join with them.
Terry Soo-Hoo, Ph.D. (51:29):
Yeah I just want to reinforce that idea that brilliant interventions are great, but they can only work when there is that sense of connection with the client. It is important to do both the interventions but to really have that relationship.
Keith Sutton, Psy.D. (51:47):
Definitely. Yeah, well thank you so much for your time today. I really appreciate it.
Terry Soo-Hoo, Ph.D. (51:57):
I enjoyed it. So certainly invite me again.
Keith Sutton, Psy.D. (52:00):
Yes, definitely will do. Take care.
Terry Soo-Hoo, Ph.D. (52:03):
Okay, great. Thank you for the opportunity.
Keith Sutton, Psy.D. (52:05):
Sure. Bye-bye.
Terry Soo-Hoo, Ph.D. (52:06):
Talk again. Bye-bye.
Keith Sutton, Psy.D. (52:09):
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