Therapeutic Strategies - Part One
Our understanding of Johnella Bird's ideas for therapeutic conversations

General

Johnella Bird has developed a collaboratively oriented resource based therapy out of the Narrative Therapy tradition. This focuses on the thoughtful use of language in order to bring forward people’s sense of agency, knowledge and resources. This work is particularly rich as a resource for mental health work. Johnella Bird’s work is particularly flexible, it does not comprise a structured method or technique of inquiry (Lowe 2005) but implementation of principles and attitudinal orientation which can be incorporated into a wide range of conversations, including the core activities of mental health work. While her approach prioritises collaboration and resources of the person seeking consultation it also acknowledges the importance of clinician knowledge, resources and therapeutic skills. Inquiry is thoughtful - informed by the inquirer’s skills, knowledge and experience, rather than from a 'not-knowing' position. There is no attempt to conceal the inequality of the power relation - specific strategies are discussed to engage the power relation and contextual environment in the service of bringing forward the agency, knowledge and resources of the person.

The Johnella Bird website outlines Johnella’s books, (Bird 2000) (Bird 2004) (Bird 2006), CD’s and teaching schedule. In the paragraphs below the authors offer snippets of the therapeutic skills we have learned from Johnella Bird as we have found them useful in our mental health work. This is a work in progress in terms of our learning and is offered as a resource to the reader to raise possibilities and interest the reader in accessing Johnella Bird’s work and teaching toward developing their own skills. We have attempted to represent much of this in our own words but have drawn heavily on Johnella Bird’s ideas, both from her books and words in teaching and supervision. To avoid impeding flow we have not acknowledged this repeatedly through the text.

There are no case studies cited here because of privacy and confidentiality issues. A number of clinical examples are cited, but with very little specific information and what is there is slightly changed, or a single example presented as a combination of aspects of two or more.

Attitude and orientation

Every moment of every conversation can be carefully focused towards the person experiencing movement. This is movement in the direction of increased experience of their own agency, knowledge and resourcefulness and possibility moving into the next steps towards the change they desire. It is this attention to fine detail of the language, form and process of a conversation which enables the incorporation of this approach into the core activities of mental health work, such as screening for mental disorders, assessment and management of risk, development of formulation, diagnosis and treatment plans, medication reviews and implementation of compulsory treatment. It involves continuous, subtle alteration in the pattern of talk which arises from the context we work in (in terms of wider societal expectations and patterns of conversation), expectations of those who come to see us and many aspects of our training which put us in the expert position, looking for pathology for which we recommend remedies.

Of course, to achieve such alteration throughout all our conversations is not an achievable goal. The motivation for the authors in making these ideas available on this website is that we have found, that even as we included some of these ideas, sometimes in our conversations, imperfectly, our usefulness to the people who consult us has increased noticeably. As yet there are no formal trials on this approach. We do not have the resources to do an intervention trial but would willingly support such an initiative, ideally a randomized controlled trial.

Like the perfect golf swing or tennis shot, the work has a deceptive simplicity and lack of apparent effort when well executed, a difference from other conversation which is 'felt rather than heard'. It comprises an attitude, orientation and subtleties of language construction which can result in a number of interventions in one sentence, as the strength of any one point in a kete (a traditional Maori basket) is dependent on the interweaving of all the threads. This subtlety and complexity makes it difficult to describe. To describe any one aspect without the others is as meaningless as one strand from a woven kete is formless. It is also what makes it so useful for mental health work. The strands are highly flexible and can be woven into any conversation. As they weave through the conversation, even when only some of them are used, some of the time, the effect on the whole conversation and the effect for the person can be significantly altered. Because we could think of no better way of doing it we have divided the following account into chunks and headings as if we were addressing only one aspect at a time but there is inevitable interweaving and overlap and repetition.

Relational externalising

Central to Johnella Bird’s approach is what she describes as relational languaging, a linguistic strategy which can be used in any conversation. Johnella Bird contrasts it with totalising language which is the prevailing language form used in everyday and professional discourse. For instance, I am clever, dumb, sad, violent, happy, confident, depressed. The structure of the sentence identifies the person with the problem. It generates a binary, either I am this or I am not this. There is an implication that these descriptions represent static attributes of a person who is defined by them.

Consider this with the example of the idea that you are confident or not confident. Everyone displays some confidence in some context, even if only in everyday tasks such as brushing teeth or buttering toast. Conversely it would be unusual to find someone who displayed confidence in every situation. Thus rather than conversing about your being confident or not, a conversation about:

“the confidence you showed when …”

is much more likely to bring forward resource. One might explore times when you have felt confident, what has contributed towards that, how things might be different if you started to develop a sense of confidence and what might indicate that feelings of confidence were starting to emerge.

Traditional externalizing is a linguistic strategy developed by White and Epston (White and Epston 1990). It involves separating the problem from the person. Ideally the person’s own language is used but externalisation has been used with OCD and Anorexia Nervosa. It opens up conversations such as:

"What sort of effect does depression have on your life?"
"How does OCD trick you into believing that if you don’t wash your hands for 20 minutes you will get sick?"

It can be used with hitting, behaviour problems, depression, etc. Rather than the person being the problem, the problem becomes the problem. It is particularly useful with a specific issue and for younger children. However, where the issues people are struggling with are very pervasive they can be difficult to separate and place outside self. Externalising ‘lack of confidence’ is somewhat awkward. Also, when traditional externalizing is of a generalized idea, such as perfectionism, OCD or Anorexia it can be quite distant from the person’s experience. The focus with relational externalizing is to explore the person’s specific experience. Once an externalized issue becomes identified it can develop a life of its own and lack fluidity. It is also possible for the externalized problem to develop a life of its own and become a kind of a monster which can become overpowering for the person. With relational externalizing the person’s response needs to be listened to carefully, with consideration for shifting or changing the metaphor.

Relational externalizing enables the person to look in on themselves in relation to the issue:

“This sense of being depressed you are describing”
“The sadness you are feeling”
“This hope/fear you hold”
“This hitting you engage in”
“The voices you hear”
“The suicidal thoughts you experience”

The difference between this and ordinary language is felt, rather than heard. It creates space between the person and the problem, but a relational connection. Rather than being separated from the person it puts the feeling or idea in relation to the person. For example:

“This hitting you engage in”

enables some separation between the person and the hitting but responsibility remains with the person.

Relational externalising leads into mindfulness, by inviting the person to reflect on their experience while staying in connection with it. It supports agency, the person is described as being active. It opens space to move out of binary and creates a platform for contextualizing:

“The voices I heard when …”
“the suicidal thoughts you experience when …”

In contrast to both totalizing language and traditional externalizing, with relational externalizing, this experience is articulated as “of me but not the whole of me”.

Compare:

"Are you suicidal?" versus "Are you experiencing suicidal thoughts?"
"Are you depressed?" versus "Are you noticing times of lowered mood?"
"Are you a confident person?" versus "Are there areas or aspects in which you have a sense of confidence?"
"Are you an OK parent?" versus "What parenting that you do would you describe as OK?"
"Are you a close family?" versus "What sorts of closeness do you notice in your family?"
"Is she attached to you?" versus "What signs of attachment does she show?"
"Have you grieved for …?" versus "What sorts of grieving have different members of the family engaged in?"
"Do you trust Johnny again?" versus "Are you noticing signs of trust starting to build again?"

This can also be helpful in third person conversations with other professionals. For instance: “That boy is a liar.”

Inquiry: “What are some of the situations where you have noticed the lying happening?”, opens possibilities.

It opens the possibility of contextualizing. If we are talking about lying which is noticed when …, then there is an opening to understanding the lying and an implication that there are times when the lying doesn't happen.

Careful listening

As with many approaches careful listening for detailed understanding is vital. This listening is done with profound respectfulness, listening for agency, knowledge and resources as well as themes which may be significant for meaning making.

For instance, where a young person has managed to get through a difficult time in hospital, it would be possible to focus on what caused it to be so difficult, the effective strategies used by the staff, phenomenology of the distress, automatic thoughts contributing to the distress, etc. Any of these has their value, dependent on context. With this approach priority is given to listening focused on the agency the young person exercised and resources they drew on in taking up what the staff offered:

"I noticed that even though I could see your hands were shaking and you seemed to be experiencing a lot of distress you took up the invitation of [the nurse] to sit down and look at possible ways of managing the anxiety you were struggling with."
"How did you make the decision to sit down and engage in that conversation?"
"What experiences have you had in the past which enabled you to put some trust in the staff?"
"Were you surprised at how well you were able to talk about what you were experiencing and join [the nurse] in coming up with strategies to manage the anxiety?"

A second example is that of a young person who had previously described disliking treatment and wanting to be released from compulsory admission. He told a clinician how much he was enjoying the inpatient unit. When the clinician inquired further he said"

“I have decided to like it here so I can go home.”

This statement was rather surprising to the clinician and could have been dismissed as indicating the statement of liking hospital was untrue. However, focusing on the agency involved in making and executing this decision is more likely to bring forward agency and resource. For instance:

“How have you made that decision, did it come to you in a moment or have you thought about it for a while?”
“Was this a new idea for you or have you experience of something similar in the past?”
“Are you finding the liking comes easily to you or do you have to put a lot of effort into it?”
“How well is it working for you, are you finding it any easier to be in hospital?"

Inquiry

In traditional mental health work questions are often asked to elicit information which the clinician will hold and use to develop assessments of risk, formulations, diagnoses and treatment plans, the effect of the inquiry on the person receiving the question is prioritized. The question can function as an invitation to the person to join us in discovery, to open possibilities, to bring forward resource, sense of agency and knowledge into conscious awareness. This is in contrast to the 'detached observer' position whereby the clinician notices, makes sense and intervenes.

Inquiry is not naive, or from a 'not-knowing position'. Considerable clinician thoughtfulness and skill are needed to develop helpful questions. The focus for content is on agency, the ‘I’, active in the present moment with values, ideas and intentions, what’s working, what’s available, looking through the chaff for the grains. Questions are informed by our knowledge and experience and made with an attitude of discovery with openness to the possibility of an unexpected, rather than a confirming answer. We need to ask the question and ready ourselves to hear the answer - open to hearing an answer which surprises us, rather than waiting for the person to answer while we develop the next question.

Inquiry can be compared to an interpretation in psychodynamic psychotherapy in that it is a way of making clinician knowledge, experience and ideas available to the person. However, in informing an inquiry the clinician’s knowledge offered as tentative, in creating possibility and the person’s response is prioritized. If the person takes up a suggestion in an inquiry in a confirming way then they can hold some agency in the discovery of that knowledge, rather than being told. If the person does not take up an idea in an inquiry which is made in the spirit of discovery there need be no loss of rapport and alliance, as there might be with an unhelpful interpretation. The disconfirming answer contributes to the discovery process and may open further possibilities.

For instance, in a situation where a young woman had been engaged in partial hospitalization for Anorexia Nervosa, her father asked the clinician involved whether structure was needed in treating Anorexia. The clinician’s knowledge and experience indicated that structure was helpful. She had the choice of telling the family this, or making her knowledge available in a tentative way, combined with an inquiry to the young woman in question who had had some experience of structure:

“In my experience young people struggling with Anorexia often do find structure helpful, but everyone’s different, how have you found the structure that you have engaged in, Melanie?”

Another example is a conversation with a young man with Bipolar Affective Disorder. He had a relapse into a manic episode after late nights including an all night party (with only very modest alcohol ingestion). It seemed obvious to the clinician that sleep deprivation needed to be avoided. However offering this as an inquiry:

“Do you think there is a connection between the mania coming back and the lack of sleep?”

opened a conversation which brought forward the value he placed on being able to participate in all night parties. This enabled them to negotiate a plan whereby short term hypnotic and antipsychotic medications were used to ensure return to a regular sleep pattern after an all night party and late nights.

Constructing helpful questions

Open questions have an important function in opening up an interview but offer the person little support in finding words for their experience. Receiving and answering questions can be stressful and require mental effort. To answer the question:

“How are you feeling?”

requires a great deal more effort than to answer the question:

“I notice you are looking down and shifting in your seat. I am wondering if the issues in this conversation are quite difficult to discuss, if some feelings of discomfort, sadness or regret are coming forward, or if you are just feeling tired. Is any of those partly right?”

Clinician effort and skill is needed to develop useful, easy to answer questions and a carefully constructed question can enable the person to benefit from our knowledge and expertise. From the knowledge we have we can offer possibilities as questions which can support the person to put language to their experience.

Making questions particular and practical is helpful:

“If I was watching from the side when the voices were getting stronger what would I see?”

Questions that are not too big are often more helpful. For instance, rather than:

“What has changed?”

use:

“Have there been any times when it has been a little bit easier to go out of the house?”

Structure and frame can focus questions:

“When you think of Kingseat (psychiatric hospital) as a place of shelter, can you tell me about the shelter it provided?”

Offering alternatives can support the person in going into detail:

“I’m interested in how you made the decision to stop the medicine, if it happened all at once, or if you wondered about it over a few days.”

Gathering threads

Gathering threads is as important as inquiry. It can be compared with summarizing and feeding back. As with careful listening and inquiry the contribution it makes to the conversation can be enhanced by use of relational language and focus on agency, knowledge, resource, etc. It slows the conversation down, gives an opportunity to consult and it can be affirming and centering for the person to hear what has been discovered spoken by the 'expert' in the room. Use of the person’s own words moved into relational language with a focus on agency and resource can open possibility for movement. To do this well, careful notetaking is needed in the interview to record the person’s words and themes which emerge. Here are two examples, one with a young man experiencing persecutory delusions and another with a young woman working to find other strategies to replace cutting:

“It sounds as if you are experiencing intrusive thoughts about the gangs being after you, leaving you with a feeling that you are not safe anywhere. It sounds as if you have experienced a bit of a shift in that you have decided to get on with your life despite these thoughts and feelings. What you describe finding most helpful in “getting on” is keeping busy, to keep your mind off them. So, might it be helpful for you if we looked at how we can support you in keeping busy, finding activities you can engage in?”
“You describe through watching TV in the evening you were able to enjoy the programmes and described little awareness of any feelings. Once the programmes were over you noticed the bad feeling coming in again. As the text fight began you remember noticing feelings of anger and sadness, but used the strategy of trying to pretend they weren’t real. Once the text fight was over you noticed the feelings gathering strength. Around the same time you noticed the thoughts about cutting coming up. You experienced some pleasure, maybe relief associated with those thoughts. Does this sound like a reasonable account of the conversation we have been having?”

Working in the present moment

This refers to bringing responses happening in the room into visibility for consideration. An inquiry about what is noticed can give the person an opportunity to notice what they are experiencing and bring it into consciousness. This enables the bringing forward of resource, knowledge and experience which otherwise might escape notice. It requires considerable vigilance, careful observation and listening and centralizes the person’s experiences and responses, indicating the importance given to them by the clinician:

“I noticed as I asked that question there seemed to be a lot of thought. What was the effect of the question?”
“That laugh, is it an amused laugh, an embarrassed laugh?”
“I noticed you smiling as your mum talked about the behaviour problems. Was there a fun aspect?”
“This is what I am noticing (e.g. sighing, lots of looking at watch). Have you noticed this as well?”
“Is there any sense that there could be a trick happening here, that I could be tricking you?”
“It seems as if I have got a lot more energy in this conversation than you do.”

Emotions being experienced in the present moment can be a useful resource. Feeling states are telling us something and we need to find a way to ask questions to put language, sensation, metaphor to the emotion. This extends the knowledge people have re the feeling state. People often are not cognitively aware of what they are experiencing. Inviting the person to bring it into cognitive awareness in relational language can make it an available resource. For instance:

“Can you put words to that anxiety/tears, etc? What was I saying when you started to become aware of it?”

Similarly the emotions we experience can be a useful resource. We need to note and hold our response, consider it in relational language and consider using it to inform an inquiry. It may be an appropriate time to slow the conversation down, gather threads, consult regarding direction, etc, and consider the effect that the response is having on the conversation.

Carefully negotiating meaning

We all use words to communicate our experience without ever having any direct access to other people’s experience to know if we are using words in the same way. There are many differences in what people mean by words such as love, respect, happiness, wellness, illness, depression, etc. If we are to bring forward the person’s experience, knowledge and resources we need to negotiate consensus of meaning. People often don’t tell us the meaning we pick up that they don’t intend. They think we know and often conclude that what we say 'must be true' because of the power relation. Thus they can lose the opportunity to bring forward the specific personal understanding of meaning they hold. A simple example comes from a situation when a young woman described herself as having been 'spoiled'.

When asked what she meant by that she turned to the clinician as an authority and asked:

"What does ‘spoiled’ mean?"

An understanding of wider societal understanding of ‘spoiled’ is of no usefulness to the conversation. What is needed is the understanding of ‘spoiled’ she used when making the statement.

Given that much of our clinical knowledge is based on collapsing and grouping people’s experiences it is useful to ask oneself:

“How much do I understand about how living with this is for this person?”

For example:

“I’ve had enough. I am desperate.”

We may think we understand desperation, but a range of possibilities can be brought forward by inquiry.

“Is this desperation meaning you are thinking about walking away, or does it give you more motivation to try and find a solution?”

Moving between ideas and practice can bring forward meaning. Clarifying terms in terms of action can be helpful in bringing forward meaning, valuing or intention supporting an action. For example, a young person described arguing back to a teacher (action) because a punishment was not fair.

“Is fairness an important idea for you? (idea supporting action) How does your concern for fairness show in your life?” (actions supported by the idea).

From a conversation with a person contemplating suicide:

“One of the things that keeps you alive is your concern about the pain your death would bring your family. It sounds as if you place considerable importance on the well-being of your family. How does this concern you hold show in the day to day?”
“The strong anger you describe coming up when Johnny got into trouble at school, does that indicate something about the love you have for him and hopes you hold that he will do well?”
“I want her to show respect.” “What sorts of things would she do which would let you know she was showing respect? If she holds a different view …”
“What would let you know if a bit more happiness/peace started to creep into your life?”
“How is love/respect shown in this family?”
“How does the concern you feel show itself?”

Bringing forward values and intentions

An intention is an idea that can be put into practice. It may not be apparent. Many of us have intentions which are an important personal resource and part of our sense of identity which have not yet been put into practice. It is unusual to find someone who does not hold intentions they can feel proud of, even if they are not played out in their actions. The following quotation from an adolescent survivor of a suicide attempt (a participant in a qualitative study) exemplifies a situation where there is a description of an intention to stop making suicide attempts which would not be apparent from the behaviour described:

"If I knew what I could [do to] stop it from happening again, believe you me, I would you know, try and stop it. Because I mean I don't like, I mean like all my past attempts I haven't really thought about it. It's just, you know, I've just done it. Um, occasionally I think I have um like when I've been drunk and depressed I've sort of set it up so that I know that my mother's coming home, you know, to get my mother's attention or something like that, but like when I jumped out of the car, you know, it was just I just jumped, you know, didn't think about it - just jumped"

Careful inquiry can bring forward intentions which might not otherwise be apparent. For instance:

“Over the days before you started smoking dope again, was that your plan, or did you have an intention to stop for longer?”
“In saying that Mary is just lazy, what are you hoping she will take from this?”

Many people hold values which influence the actions they engage in but are not available in their conscious awareness. Bringing these into consciousness can enhance sense of the ‘I’, active in the present moment. Values (and intentions) can often be brought forward by exploration of how a decision is made. For instance:

“Given that you came here today because your mum wanted you to, does that mean that you give some value to her opinion?”

With someone who has lowered mood but stops antidepressants because they do not want to depend on medication:

“Does this indicate a value you place on depending on your own internal resources?”
“What is the history of this value in your life?”
“How does this value affect other decisions you make?”
“Several times during the conversation you have mentioned not wanting to cause others harm and you have also talked about helping the old people at work. Is caring for others something you value?”

With a young person who says:

“I feel as if I have to take the Ritalin (methyl phenidate) because it helps me concentrate on school work”

inquiry could focus on a sense of compulsion, how the medication helps concentration, etc. However, agency is more likely to be supported by bringing forward the decision to value schoolwork:

“Is concentrating on school work something you value?”
“How did you come to decide this was important?”

Moving out of binary

A binary allows only two positions, even being positioned on the positive side of a binary is precarious. For instance, if I focus on being a good clinician then if I am conscious of doing less than optimum practice at some time I am at risk of slipping into the role of being a bad clinician. However, if I am aware of having certain practices, skills, values, knowledge, experience, etc which I engage in, then those are not wiped out by my finding I have areas in which I need further development, practices I need to look at doing differently, or that on a certain day, in the context of stress I did not use some of the strategies and skills I normally would. Similarly with the question above about being an OK parent.

Or one might ask:

“Is there anything good enough about the parenting that you do that CYFS [child protection agency] hasn’t noticed?”

Moving out of binary facilitates negotiating engagement. We need not be limited to considering having or not having trust, anxiety, etc. There might be beginning trust, fragile trust, or we can talk about the process of developing trust. Similarly there is anxiety which works well to keep us on alert when we need to be, or stimulates focus in a situation like an exam. Careful listening, inquiry and gathering threads can support negotiation of a consensus of meaning and develop language for the in between.

Context

Fleshing out the role of context in relation to an experience can support the possibility of movement. It mitigates totalising by focusing on a range of factors, any of which may be available for the person to have agency in relation to.

Moving focus from “I am suicidal” to “the suicidal thoughts I experienced when …” opens up the idea that these thoughts occur more in some contexts than others, that they are not a static part of self. With this can emerge a sense of possibility for movement. It can also bring forward a knowledge of what supports this experience, practice or idea.

Detail, including emotional experience is important in generating context:

“Step me through it.”
“What is the history of this idea, has it been around for a while?”
“How is this idea nurtured, supported and understood?”

Look at the effect on the relationship, person, etc:

“Who notices the caring you do/the effort you are making?”
“What would let you know if they noticed?”

It can be that the context needs to be addressed for the person to be able to exercise agency

“Given these circumstances how can you be a good enough parent?”

Context is about detail - when, why, who, before, like, making sense, meaning. Context can have a powerful effect on the process of developing engagement:

“Have you ever had a good experience with an institution such as this? … How can I support you to let me know if this conversation is starting to feel like that? …How easy is it to be here given that…?”

This can include effects of gender, institutional, political and cultural context.

Researching difference

In everyday and professional life we are bombarded with masses of stimuli and manage this by looking for sameness. People reading this will be connecting the ideas with their own practice and knowledge:

“That is just like ….”

If we did not do this, treated each sensory input as unique we would not be able to function. The process of making a diagnosis is that of looking for sameness. This is helpful for us as clinicians as it enables us to bring forward knowledge and experience from other people, situations and reading. This is helpful and we could not manage without it, but we risk losing a lot of detail. We may not find difference without looking for it. Small changes or steps are often not big enough to notice. If there are changes, there may be some agency and so we need to bring that forward:

“You notice the suicidal thoughts are not quite as strong at work? Do they start getting stronger as soon as you leave, what about lunchtime?”
“I notice a difference between you and your mum in how much enthusiasm you each have for your going back to school? How do you understand the difference?”
“I noticed in the beginning of the conversation you seemed to be talking more freely than you are now. Has something I have said made it less easy to talk? Are you noticing some judgment or criticism?”

Working with time can be another way to bring forward difference. For instance:

“Has parenting always been a struggle?”
“If you could take some of this memory with you what difference would that make?”

Imagination as a therapeutic resource

To imagine something, you need some knowledge about it. Thus to articulate what is imagined can bring forward this knowledge and the possibility of negotiating moving towards it. There is a connection between this and the miracle question in solution based therapy (O'Connell 1998). However, in this approach we are looking for subtle differences which might seem possible to reach and which can generate ideas as to steps to move towards them:

“What would it be like if ….?”
“As it started to change, what would be the first sign?”
“What would this family be like if the children did what parents asked some of the time?”
“This judgment that you are making, of the parenting you do, if you were to put it aside what would be different?”
“If you thought it was possible to re-develop trust, what would it be like, what would you hope for, what would be different?”
“If you were to be the nurse/OT/doctor etc you really want to be, what would you be doing?”
“If Koro (grandfather) were here, sitting over there, what would he be thinking, what might he say?”

Focus on presence rather than absence

Focus on presence rather than absence is more conducive to optimism and movement. Often we are presented with concern about a lack of self esteem, confidence, respect, etc. In this case the person can be invited to use their imagination to bring forward the ideas they have about the presence. For instance:

“How would your life be different if you started to develop some self esteem?”
“If some self esteem started to develop, what would be the first sign?”
“How would you tell?”
“Who would notice first?”

In response to “No one ever listens to me”, one might inquire “What would let you know that listening was happening?”

A young man who felt that a young woman looked straight through him could be supported to focus on presence. “If they did see you what would you like them to see?”

Other possibilities may include:

“What is the conversation like when the fighting is not happening?”
“When I remember the way they talked about what happened, I am surprised I didn’t go mad."
"When you remember that time, what supported you to hold on to the reality of your experience?”
“I sat through the inquiry with my partner squeezing my hand. It helped me to feel I existed. … Tim’s hand was marked from my fingernails. I just held on."
"In the holding on, what were you holding on to?”