Therapeutic Strategies - Part Two
Applying Johnella Bird's ideas to core mental health activities

This section outlines some specific ways Johnella Bird ’s work can contribute to enriching and adding value to the core activities in mental health work by careful attention to the way we use language.

Managing the power relation

A significant differential is present in the power relation in a clinical encounter. This is a challenge to achieving collaborative work where both parties can meaningfully participate in negotiating the encounter. Otherwise it can be like a situation where a bulldozer is negotiating with a bicycle. This power relation contributes significantly to the reluctance of the people we are working with to bring forward their knowledge and ideas into the conversation. Just being ‘nice’ or attempting to conceal the power relation has little real effect. It also risks making it harder for the person to identify the experience of having their knowledge trumped and to challenge the process or the content of the conversation.

We can address the power differential more effectively if it is exposed, rather than concealed. We need to take up the opportunity to use the power we hold in positive interventions to bring forward agency, resources and knowledge of the people we are working with. This requires more than just an intention. It also requires constant vigilance for opportunities to move it into action.

Addressing the power relation is one of the strands woven through every action and intervention in Johnella Bird's work. Specific strategies can include taking control of the conversation and slowing it down, making positive interventions to elicit and carefully listen to and inquire after, people’s responses as in working in the present moment, tentative telling and inquiry, consulting with people as to the direction and content of the conversation, providing support to people to articulate their ideas around maintaining limits to exposure, etc.

Working in the present moment

In the context of taking a history, doing psycho-education, developing action plans, etc, the clinician needs to focus on a longitudinal, overall view and attend to content. There is often material which needs to be covered, a range of disorders which need to be screened for, etc. Refocusing attention on processes which are happening in the room can appear to be a deviation which take up time.

Noting non-verbal responses from people and events in the emerging clinical relationship and bringing them forward can significantly increase the usefulness of the conversation. Wandering attention, a lot of sighing, tears arising, a warm laugh, etc, can indicate a response which may not be available to the person’s conscious processing. They may not articulate it because of the power relation. The very noting of the person’s apparent response, in a tentative, respectful way, contributes towards managing the power relation.

It is a practical demonstration of the value put on the person’s response and it defers to their authority in identifying it. On a pragmatic level it can also bring forward differing ideas of the usefulness of the conversation. If brought into the open, these differences can be addressed.

Managing judgment

Respect can alter the perception of judgment and as depth of respect is developed judgment will come to the fore less readily. However it can be a powerful force in a clinical encounter. Experiencing judgment can shut down a clinician attempting to work collaboratively. This is because of our understanding that communicating the judgment is unlikely to be helpful. An obvious alternative is silence. However, this may mean that an opportunity is lost. Where the clinician is experiencing judgment we may well be responding to something of significance. There are also situations where we cannot afford to be silent when experiencing judgment as there may be significant issues relevant to the safety or well being of the person which need to be addressed.

A more effective alternative to silence is to 'hold the judgment and make an inquiry'. This inquiry needs to be made with an attitude of profound respectfulness holding a readiness to hear the answer. General examples might include:

How well does that work for you?”
How did you make that decision?”

In listening to parents speaking in a disparaging way to children:

Is this news to Johnny?”
What are you hoping he will take from this?”

In the process of exploration of this kind many surprises are possible.

An example of this comes from a father with a history of drug addiction and criminal charges. He showed reluctance even to engage in conversation around contact with his eight year old son who was experiencing difficulties. This apparent lack of interest in contact with his son was perceived by the staff with judgment. However, respectful inquiry with working in the present moment opened a fruitful inquiry:

"I notice when I asked you about contacts with your son the expression on your face changed. There was a slight frown."
"I don’t want to visit him."
"I notice as you say this you shift in your seat and look away. Is there some discomfort in talking about visiting [son]?"

[Interval while man sat in still silence, then replied quietly, looking down with emotion]

"I don’t want him to have a father like me."

This opened the way for a conversation about his intentions re parenting (the kind of father he did want his son to have) and his desire to be the positive role model for his son that he never had, what might be the first signs of change in that direction and the steps he might take to increase the likelihood of it coming about.

Orienting for an Assessment

People are likely to arrive to see us expecting us to ascertain knowledge about them, find pathology and recommend potential solutions. We can frame our contact in a way more oriented towards presence rather than identifying and addressing absence or pathology:

Our job is to do what we can to support you to live your life in the way you are wanting to. We will start by listening to your concerns and asking a lot of questions. The purpose of this is to get to understand enough about the issues you are facing, your experiences, your family and the life you are wanting to figure out if we can be helpful.”

We have found people very receptive to this orientation.

The agenda that, in the process of the conversation people will experience an increased sense of agency and their own knowledge and resource, is not so easily taken up by people. But it is a powerful frame for the clinician. Each interaction has the potential to be empowering. Each inquiry and each response can be focused and constructed to open possibility and facilitate discovery.

Disclosing referral information indicates openness and transparency which can support collaborative process. However, care may need to be taken. Referrals can sometimes be made in pathologising, totalising or deficit based language. Disclosure of this can sometimes be managed by using relational language. For example:

Dr X wrote a letter indicating a concern that you may be experiencing suicidal thoughts, struggling with depression, hearing voices which are getting in the way of your concentration, etc.”

It may be most useful, particularly with a child or young person brought by their family, to explore what they know and understand about the referral. This gives an opportunity to centralize their experience and hear the language they use.

Negotiating engagement

For engagement to be usefully negotiated as a joint enterprise, both parties need to have agency. Careful listening for agency, knowledge and resource to inform inquiry and gathering threads is needed to support the person’s agency. This is further developed in the discussion of supporting the person with respect to limits to disclosure. Moving out of binary and developing a language for the ‘in-between’, limited or potential or partial engagement, rather than engagement or not, can be particularly helpful. Eliciting a small amount of interest can be more achievable than eliciting a commitment. For instance:

Is there a little bit of interest in what I am talking about? … Sounds like a reluctant interest, do you have some openness to following through with the conversation and seeing if it seems useful?”

Trust can also be more usefully negotiated on a range of continua, rather than an all or nothing phenomenon:

It sounds as if there is a wavering trust. Are you considering how much belief you have that we are here to help you?”
Is there a beginning trust?”
Trust building is something we will need to do together. How can I support you to participate?”
If we start to go beyond the limits of the trust, how can I support you to let me know?”.

I don’t know” can support an inquiry as to whether the person holds some openness of mind. Inquiry as to what persuaded the person to turn up given that they thought it was a waste of time may open a conversation of possibilities, even if it is around coercion from someone else in their life:

Given that you came because your wife nagged you, does that mean you value harmony in your household?”

Concerns about judgment and shame are common, once elicited they can be addressed. Helpful inquiries might include:

"Are you experiencing a concern I might develop a judgment towards you?"
" If you notice that judgment start to creep in, how can I support you to let me know?"
"What was the accusation that you noticed/felt/experienced?"
"What is the history of this idea? Has it been around for a while?
Do you want to know what I was intending to say?"
"Will you believe it if I tell you?"
"How is the belief going?"
"I wouldn’t be surprised if it was a wavering belief."
"Is there anything else I can do to support this belief?"

Negotiating content areas for focus

Content areas for focus in the interview need to be explicitly negotiated. If as mental health professionals we see someone who has an experience, syndrome, etc, which could be helped by one of the evidence based treatments we have to offer and we don’t elicit it we have let them down. We know what we have to offer and it is our responsibility to elicit possible areas where this might be helpful. It is also our responsibility to use our clinical skills to bring forward the concerns of the person consulting us.

There is so much we could talk about, we need to make some choices. From the referral information the sorts of things I think will probably be helpful to cover include …”
Which of those sound important to you? Are there some things I haven’t mentioned?”

This needs to be revisited throughout the conversation. Gathering threads can be a good opportunity for this. For instance:

How does this fit with what you think is important?”
Are we moving in the direction you think is most useful or helpful?”
Which bits are you most interested in?”
Are we talking about the right stuff?”
this brings up an idea we call ‘depression/OCD/psychosis’, I’d like to ask some questions around this. Is that OK?”

It can be helpful to this process if we make our agenda explicit, and time can be specifically negotiated. For instance:

there are a number of issues which you have brought up. I also think it is also important to clarify whether antidepressant medication has a role here. Shall we spend 10 minutes on A, 12 minutes on B and 13 minutes on C?”

Sometimes these negotiations are not straight forward. For example, a person may identify an issue of importance but move to something different.

"This person doesn’t seem to know what they want. They are saying they want to talk about Y and yet they talk about X."

This can raise senses of confusion and frustration in the clinician. It is important to hold these responses, maintain an attitude of respectful commitment to bringing forward people’s knowledge and make the issue explicit and inquire about it.

I notice we’re talking about X, you’re saying Y is important. How do you make sense of this? How do you place X? How do you see X as linked to Y? What do you make of this difference?”

In doing this exploration, there is a commitment to the view:

There is something of worth here that I am not getting. What can I do differently to get a clearer understanding?”

It may be important to bring forward some detail as to how the person is making their choices. It may be that there are challenges in addressing certain areas and it is more helpful in engaging with addressing those challenges than avoiding the issue.

What draws you to this, rather than that?
Is one easier to talk about or is there a worry about judgment or criticism?
If we could find a way to make it easier to talk about do you think that might be helpful?

Supporting limits to disclosure

Traditionally clinicians have advocated maximising verbal disclosure via the use of empathy, for instance Shea (1998). However, management of verbal disclosure can be much more sophisticated than this. Talking about traumatic events can re-traumatise. One of the aspects of injury experienced by people who have survived abuse is a transgression of personal boundaries by someone in a position of trust. This can be repeated in the context of a conversation with a mental health clinician and is the origin of the play on words of 'therapist' as 'the rapist'. A common strategy people use to manage distressing memories is to put them out of their minds and so maximizing verbal disclosure can undermine this strategy and expose them to further distress. From the expert position monitoring comfort levels can be done whereby the clinician can monitor distress and manage it, perhaps suggesting the conversation be deferred.

Alternatively the client can be offered the opportunity to self monitor:

I am going to ask a lot of questions. Some of these may be difficult to answer. Nobody can make you talk. If there is something you don’t want to talk about just let me know.”

This can be helpful in developing rapport, but depends on the person to identify the concern and feel able to state it. We all exercise agency and have considerable personal knowledge an experience which we exercise on a daily basis in deciding how much to disclose to whom. Engaging in a mental health assessment requires different decision making processes from those required in everyday life and few people have much experience of them. This lack of experience, the vulnerable state of the person at the time of seeking help from us and the power differential all contribute to the risk that the person may push past their comfort zone and feel exposed in a way they find diminishing.

It is part of our responsibility, in holding the power we hold in the clinical interaction to support the person in taking up a role in negotiating their boundaries. Thus identifying a sense of unease a person is experiencing around limits to disclosure becomes a prioritized activity. Rather than seeking to dissolve, or support the person to push through, the sense of unease, it becomes important to let people know we value hearing about the hesitations or unease they experience. We can support this communication by exploring how unease is likely to come into awareness and what we can do to support them to communicate it. By making explicit what we are noticing in the present moment we can support that process. For instance:

I notice a change in your expression and the amount you are talking in this conversation. I’m wondering if you are experiencing a level of discomfort and how it is likely to be for you if we keep talking about this.”

Identification of unease around speaking about an area can be the beginning, rather than the end of the conversation. The unease identified needs to be valued, clarified and understood:

I find it helpful for you to let me know what areas we need to take special care around. I would like this conversation to be helpful rather than just causing necessary distress. I am getting the idea, from what I have noticed and what you have told me, that talking about the illness your mother went through and her death bring up strong feelings for you. Is that right?”

There are a range of possibilities as to how it might be helpful to proceed and these can be negotiated with the person. They may be put aside in the short term, discussion as to how the person usually manages these feelings and how that works for them may be helpful, negotiation preparation for having the conversation or exploration around how the person is making the decision:

"If we were to (continue to) talk about this what would happen?"
"I’m wondering what would you need for it to be OK to talk about this?"
"I’m wondering if it’s bringing up a concern I might judge you, uncomfortable feelings which you are used to putting aside?"
"Does either of those seem partly right?"

Some people have found it easier when tough questions come up to leave the room and have a break and come back. On returning:

"I’ve noticed that you chose to take a break. Is there anything you can let us know which might be helpful in understanding Johnny in what was difficult about the conversation when you chose to leave?"

Developing presenting history

Careful use of language can have a powerful effect on the experience a person has in the context of history taking. Using relational externalising to ask a person what they have 'noticed' about a symptom languages them as active in relation to the symptom. Researching differences, role of context and movement through time fit with a standard history taking process. Focusing on how the person makes use of these is less routine but can give important information while enhancing sense of agency:

Have you noticed any differences in the strength of the worry you are experiencing [about ending up on the streets] at different times?”
Have you noticed if the voices you have been hearing are more when you are on your own, busy, with others etc?”
How do you cope with the voices?”
Given that they are less when you are with others do you find you are deciding to spend more time with others, or choosing to be on your own?”

Using imagination as a therapeutic resource to focus on imagined presence of desired outcomes or movement can orient the conversation towards movement in the desired direction:

If the depression was starting to lift, what would be the first sign?”
What difference will it make to your life when the worry starts to lessen?”
Has there ever been a time when life felt worth living?”

We can engage people in thinking differently about their experiences.

What difference would it make if you saw yourself as ‘struggling against the odds’, rather than ‘I am an idiot’?”

Past psychiatric history

Inquiry can focus on bringing out the experience and knowledge the person has acquired.

Have you ever noticed anything like this before?”
How did you get through it then?”
In the experiences you have had with people like us, what memories do you have of what felt helpful or not?”

Researching difference and context can be helpful:

What is different this time from previously?”
What was happening in your life then which helped you get through?”

Family psychiatric history

Similarly, inquiry round this can focus on resources the family may have:

Is there anyone in the family who has experience of this sort of thing?”
What are the similarities and differences between this experience and their experience?”
What do you know about who in the family was helpful at that time?”

Developmental history

Rather than focusing on deficits, trauma, etc, which might undermine the person’s ability to function, a developmental history can focus on personal style in engaging with life, active ways of approaching and managing problems, strategies which have been helpful and opportunities for development. For instance, focus on presence rather than absence:

What sort of learning environments were you exposed to when you were growing up?”
"What sort of role models did you have the opportunity to learn from?”
What sort of challenges did you deal with?”
"How did you engage in social relationships/school/work, etc.”

Trauma histories need to have the focus:

How did you get through this? What kept you going?”

rather than,

How has this damaged you?”

If a developmental history is being taken from a parent, sense of agency can be promoted by asking them about what they noticed, felt concerned about or felt might be helpful in understanding the situation.

Alcohol and other drug history

Johnella Bird’s ideas can build on Motivational Interviewing (MI) (Miller and Rollnick 2002). MI works to bring forward ambivalence and personal knowledge and experience about the effect of substance use on people’s lives by careful listening, inquiry and summarizing. These conversations can be enriched by incorporating strategies from Johnella Bird’s ideas. Making a choice to use substances is usually supported by values and intentions (even if this is valuing spontaneity), as strategies to manage a difficulty. Bringing forward values and intentions can make these available to the person as a resource.

"How did you make the decision to use alcohol again?"
"It wasn’t a decision, I just let go and went with it."
"This ‘letting go and going with it’ strategy, is this something you use in other areas of your life?"
What is the history of the ‘letting go and going with it’ strategy?"
"When you use it, is it absolute or is there sometimes a bit of careful thinking which goes with it?"
"Is it a strategy which works for you?"

Mental state examination

Inquiring about symptoms relational externalising can increase sense of agency and mindfulness, promotes a relationship with the person who has some agency with respect to the symptom.

Are you noticing any unusual experiences?”
Have you had a sense that you can read other people’s minds, or that others could read your mind?”

We can inquire for agency:

As I tell you that I am not trying to harm you but am interested in helping you, are you working out in your mind whether to believe me?”
As you experienced this thought that the man was going to kill you did you find yourself questioning it at all, or accepting the truth of it?”

Researching difference and movement can bring forward detail:

How did you develop the sense of certainty you have that spies are after you?”
Are you aware that I don’t hold the same certainty about this that you do? I’d like to invite you to discuss the difference between the view you hold and the view I hold. As I suggest that do you notice a little bit of interest, no interest, some discomfort, or something else?”

Working in the present moment can increase the richness of the understanding we develop with respect to engagement, rapport and insight:

I notice that as I talk about the idea of illness and medication you look down and away. Is that what you notice? Does that indicate that you have very little interest in that discussion?”
From where I am sitting it looked as if you felt a bit uncomfortable or annoyed when I started to ask you about voices and cameras watching you. Did you notice any feelings like that? I noticed, as I asked you about reading minds, that you looked up and looked animated. Do you have some interest in that?”

Formulating can inform inquiry

As clinicians we are trained to develop formulations, hypothetical understandings of the elements in the person’s presentation and story which makes sense of it. When these are fed back to the person the experience that sense can be made of their story can be containing and they can feel confidence in the clinician who is able to understand and make sense of all this. These formulations can be offered as a question. For instance:

Do you think the abuse you experienced as a child has hampered the learning you were able to do around identifying appropriate boundaries between a stepfather and a young child?”

is offered as a question with the potential of being accepted or not. But using the hypothetical theme underlying the explanation to form a question is more likely to bring forward the person’s knowledge, and with it a sense of agency and more potential for movement:

How do you think the experience you have had of sexual abuse affects the parenting that you do?”

This needs to be made genuinely as an inquiry with an attitude of discovery and openness to hearing the answer.

From a social constructionist epistemology there is less interest in ‘underneath’ explanations than in active systemic processes. There is a range of possible formulations, rather than a right explanation. Formulations, as with diagnostic labels, can be evaluated by their effect and usefulness, rather than ‘truth’. Vicious and virtuous cycles can be helpful ideas as they imply multiple openings for small steps effecting significant change.

Talking about diagnoses

Diagnostic labels have a special role in mental health services in that our funding to provide care can be dependent on identifying and applying a diagnostic label. A social constructionist epistemology opens up talk about diagnoses as ideas, which can be more or less helpful, rather than entities or truths. DSM IV and ICD 10 diagnoses have been carefully and explicitly constructed to facilitate communication among professionals and focusing of research enabling the development of collective wisdom.

Thus depression, for example, can be offered as an idea which has generated potentially helpful collective wisdom:

"Everyone feels sad and happy at different times, sometimes the sad, angry, negative feelings get a life of their own and they affect your body, your sleep, your thinking, etc. This can become a self-reinforcing cycle. That’s what we call a clinical depression. It’s a common experience which means there is quite a lot of collected knowledge about strategies people have found helpful. Would you like to hear about them?"

This contrasts from the quotation from the doctor patient in the beginning discussion of the fragility of holding of personal knowledge from a patient role:

"He told me I was depressed and that I needed antidepressants."

Offering people a choice as to whether they want to hear our thoughts, tentative telling or inquiry can be effective in making our views available but leaving the person room to take them up or not. Examples include:

I’ve got a way of understanding about this which might be helpful, would you have any interest in hearing about it?”

In a clinical situation where a teenager presented with classic symptoms of a psychotic episode the clinician reported:

I could see, that when I said that their son had a psychotic illness, I lost the family.”

The accuracy of the observation was borne out in that the family subsequently disengaged, moved, and their son lost the current possibility of psychiatric treatment. In similar situations presenting of diagnostic ideas in a more tentative way and noting and naming similar responses:

I notice your expression changed [you looked away, etc] when I mentioned the idea of ‘psychotic illness’. Do you have some experience of this idea?”

This has enabled family members to speak of their experiences of relatives who had experienced disappointing outcomes following engagement with mental health services, or ideas about spirituality and other explanations. While this did not result in immediate taking up of psychiatric treatment on offer, it enabled connection to continue and the conversation to remain open.

Developing possibilities for action

Clinical recommendations involve making a best guess based on emerging knowledge of the person consulting us and a breadth of knowledge about other people from our experience, training, reading, etc. Our information is based on probabilities. Thus feedback from the person is very important, to the initial ideas and as treatment progresses as to how it is going. This can be framed in a way which values personal knowledge:

I have a lot of knowledge about depression in general but am only just getting to know you. You know you. So it will be very important in sorting out what is likely to work best for you to hear your feedback. "
From my experience, what people have told me and international research, the most likely thing to help someone in a situation like this is X, Y, Z. What do you think of the sound of them? What do you feel most interested in engaging in an experiment with? It will be important for you to let us know how it is working for you.”

Talking about medication

Overstating the level of certainty we have regarding the effectiveness of medication is particularly tempting. Few of our medications (except stimulants for ADHD) give a benefit in randomized controlled trials to more than one in three people. Randomised controlled trials can be explained, with the proviso that not everyone in the treatment got better and that some of the people in the placebo group got better. The person can then engage in a risk-benefit analysis around whether or not to engage in a trial to establish whether they are one of the people who will benefit. (Empirical research on the effect of this approach on the placebo response would be of interest.)

Difficult situations

Johnella Bird's ideas are particularly useful in some difficult clinical situations, particularly those involving strong emotions. Relational externalizing allows us to lay out emotionally intense issues for discussion with some space from the emotional intensity they carry.

When one person is abusing another in a clinical situation, it is important to manage the power relation to interrupt the process and slow it down and engage in careful listening and respectful inquiry. . Possibilities include:

Is this a style of conversation you have frequently?”
Is there anything new in this conversation today?”
Does it work for you?”

We can use the power we hold to change the form of the conversation, stop the interaction between the people in the room and interview each individually.

Inquiry to bring forward values and intentions can open space for movement. For instance:

John, what were you hoping Paul would take from this?”
Amelia, You seem to be taking considerable care to clarify the concerns you have about how John is functioning with a range of examples. Are you hoping that if I fully understand it I will be more likely to be able to help.”

In response to a threat:

If you … I will kill you”

a carefully constructed respectful inquiry can change the whole tenor and focus of the interaction:

In saying this are you hoping Mary will take this literally or figuratively?”
In saying this is it a warning or a threat?”
Andrew, I notice you are expressing very strong emotions here. Are the strength of the emotions an indication of the level of concern you hold about Paul?”

With someone who will not talk the strategies described above with respect to negotiating engagement can be helpful. Tentatively offering options in relational language and languaging the inbetween can support a person to engage.

Sometimes when people find it difficult to answer questions there can be all sorts of reasons. Some people have had an experience of or a worry about information they have given in a situation like this being treated inappropriately, told to someone they did not want to know it. Many people who have been through difficult times manage the emotional discomfort they experience by putting the situation out of their minds. If this is one of the strategies you use I am wondering if you might have a concern that if you engage in the conversation you will find yourself talking about difficult issues and these feelings will come up meaning you will experience a lot of distress. Sometimes people find their thoughts are going so fast it is difficult to focus them on one question. Are any of these a little bit true for you?”

When talking is difficult

For people whose cognitive processes are so disorganized in the context of psychotic thinking language based approaches are of limited benefit. The principles of Johnella Bird’s work:

support the 'being with' which is needed.

For people with prominent negative symptoms, limited spontaneous speech and motivation to engage with other people, the attention to questions which are easy to answer supports their verbal engagement. Open questions are often quite unhelpful in this context. They leave the responsibility for the content and focus of the verbal production with the person answering the question, with all the attendant possibility of 'getting it wrong'. Carefully constructed questions around activities such as getting out of bed, engaging in a conversation or going out of the house can bring forward a surprising amount of agency, values and intentions:

As you are lying in bed in the morning, is this enjoyable lying in bed, or more like not wanting to get up?”
I am interested in how you made the decision to go up the road to the shop yesterday when you have been finding it so hard to get out of the house? Were you surprised that you decided to go? Was it something you had thought about before you went, or a sudden idea?”

Once people who have difficulty generating talk have responsed to an inquiry the process of gathering threads can be particularly valuable. Given that the verbal production of ideas is so limited, care in enabling them to hear the themes and ideas they have brought forward spoken in the context of the power relation with a focus on agency in their own words, can be an important experience.

Compulsory Care

Undertaking compulsory care is particularly challenging in the context of a commitment to work collaboratively. At least in the moment this comprises a gross limitation on the person’s agency. Conversations and care can be conducted in a way to maximize the person’s agency within limits. Careful listening to support inquiry and gathering threads in relational language focusing on agency and resource can still be possible. A social constructionist epistemology supports our awareness that our assessment that compulsory care is necessary is just that, our assessment, from our frame of reference with the knowledge, skills and information we have. It is not a disembodied statement of truth. It can be presented explicitly as this:

From what I know about the experiences you have been having and how your thinking is working, I have come to the belief that leaving hospital at the moment would put you at risk. I am aware that the idea you hold about this is very different. It is also possible that you could be right and I could be wrong. However, in my position here I am held responsible for making this call. In that position I am also supported by the law and the police. For the mean time you have no choice but to stay here. You can apply for a review of the decision I am making by …”

Talking about suicidal feelings

The benefits of all aspects of Johnella Bird's work are particularly apparent in this context. Using relational externalising to ask whether the person is experiencing suicidal thoughts languages them into the conversation as an agent in relation to the experience of the suicidal thoughts or urges. This gives them some separation from the thoughts. It also supports moving out of binary, in contrast to:

Are you suicidal?” or Can you guarantee your safety?”

Relational externalising also supports contextualizing of the suicidal thoughts/urges, opens up the conversation to:

the suicidal thoughts you experienced when …”.

This can bring forward knowledge as well as the possibility of movement if the suicidal thoughts are not described as a fixed attribute of the person, but in relation to circumstances which may be able to be addressed. Researching difference through time can also support the possibility of movement:

You were saying the suicidal thoughts are the strongest when you and your mum are arguing. Do you notice them as soon as the argument starts, or do they take a while to gather strength?”

How did you get through?” can move the focus to agency.

"What kept you going?" or "Has there ever been a time when life felt worth living?" support focus on presence rather than absence.

Working across and within cultures

There are a range of features of Johnella Bird’s work which are very helpful in working across cultures. Carefully negotiating meaning and minimizing assumptions increases the possibility of useful understanding. Negotiating engagement gives an opportunity for cultural differences to be made explicit and the person consulted on the experience they have of them in the conversation. For example, in many Asian cultures the custom is for the doctor or health professional to tell the person consulting them what they should do. Making explicit the different approach being offered in collaborative practice allows this to be specifically negotiated as an option.

Practices and values around confidentiality can be very different across cultures and making this explicit means expectations can be addressed. There are cultural differences with respect to who might speak for whom and who can and cannot contradict others. A clinician from another culture can be very useful in making these practices explicit and opening inquiry as to how well they are working in this context. Researching differences can bring knowledge that the person has about their culture into conscious awareness, thus it becomes available as a resource. Working in the present moment, whereby noticing of changes in facial expression, body language, tone, etc, are explicitly addressed. Understanding of these is thought particularly important in working across cultures as it facilitates bringing forward of meanings in the conversation which may not otherwise have been appreciated by the clinician.

Paradoxically, these aspects of the work are also valuable in working with someone with apparent cultural similarity. In this situation there may be increased risk that understanding will be assumed. In a context of apparent cultural similarity, contradicting such an assumption may be even more difficult to challenge than where there is obvious cultural difference, particularly as in the context of the power relation and the role of help-seeking, the person is likely to feel the experience they have is to be valued less. There may also be a perception that to challenge an assumption of sameness is to risk being 'outside' and lose a sense of connection.