Therapeutic Strategies - Hints for getting started, potential pitfalls and remedies

Hints for getting started

Changing the flow of our clinical work is challenging. The first step is in recognizing and valuing the possibility. In practical terms, the easiest way to shift our practice is to consider after meeting with someone what alternatives may have been more helpful rather than trying to change while actively engaging in a conversation which can be very confusing. Practicing relational externalizing in a range of contexts can help shift languaging practices. There are some simple, low risk, widely applicable questions which can help:

In response to trauma or any difficulty:

“How did you get through?, What kept you going?”

In response to disclosure of a course of action attracting judgment:

“How did you make that decision?”
“How well does that work for you?”
“What were you hoping when you …?”

In response to talk of lack or absence:

“What difference would it make if …”
“What would let you know if things were starting to improve?”

In negotiating engagement:

“Do you have a little bit of interest in …?”

At any time:

“Are we talking about what is most interesting to you?”
“When you noticed this experience/thought/feeling what did you do?”

Inquiry can be guided by the internal question:

“How well do I understand what this experience is like for this person?”

Slowing the conversation down, gathering threads checking with the person as to whether this is a reasonable account of the conversation (or whether there are other important aspects which need to be included) and consulting as to which aspect of the threads gathered is of most interest to them to follow, can often be helpful.

Potential pitfalls and remedies

As clinicians moving into resource-based work, we can experience considerable frustration when someone’s resource appears so apparent to us but not to them and we can get seduced into attempting to convince them. For instance, when someone is telling us about how useless they are we might list the achievements we have noticed, telling them how well they have done against the odds. While people can experience this as supportive, there is a risk that they will argue back, both out loud and in their heads. Where a person is engaged actively in arguing against their agency and resource, it is difficult for movement to happen. Exploration can be more helpful in supporting agency, resource and movement. For example:

"When you hear me list the things I think you have achieved, what response do you notice in yourself?"
" Is the arguing back automatic or does it have some thoughtfulness in it?"
"How does this sense of uselessness affect how you are operating as a parent?"
"How do you manage to keep going with this sense of uselessness?"
"Could there be anything you could imagine happening that might lessen this sense of uselessness slightly?"

Asking too many questions can be unhelpful. People can feel persecuted. The way examples are presented here as lists of questions is potentially misleading. Careful listening, using the power relation, and gathering threads in relational language are as important as careful inquiry. Risk of people feeling there are too many questions can be addressed by a conscious attempt to gather threads at regular intervals.

As we are moving into the process of thinking in a different way, it is possible to develop active and harsh self-judgment processes. One of the risks in this is that we are less available to listen and are focusing more on what a good question would be rather than on careful listening which is the basis of helpful questions. Noting our responses in relational externalising language to ourselves and slowing the conversation down, can be helpful.

"There is a lot you are saying here. I would like to slow the conversation down so I can get as clear an understanding as possible."

The people we work with tend to be very forgiving. It is possible to be quite honest about this.

“I have an idea I’m wondering about here, I am not sure how well I am going to be able to put it into words. I’ll do my best and can you let me know how much sense it makes to you?”

If in doubt, gathering threads, in relational language using the person’s own words with some observations in the present moment followed by a consultation.

"This is my understanding of some of the things we have covered. For instance, I noticed that you looked particularly animated when we discussed A and B and looked a bit quiet when we discussed C. Is that similar to what you noticed? Which of these do you feel most interest in?"

The final pitfall in adopting this way of working is loss of narcissistic gratification. What we have found is that when we feel we have done our best work, the people we feel we have been particularly useful to seem more aware of their own resource than ours. There has been a lightness to the conversation (Talk That Sings) and it has been our impression that people have left with a sense of ‘It’s not so impossible after all, I can manage it.’

The sense that we have done something incredibly skilful does not seem to be at the forefront of their minds. There is less narcissistic gratification of being lauded as a wonderful clinician in working this way. But work feels lighter, there is less weight and burden, aspects of people’s lives and ideas which might previously seemed quite ordinary acquire much more interest. We never know what we might discover in a conversation about getting out of bed or doing the dishes.