Often we hear therapists begin a reflection, clarification, or suggestion with one of these stems:
I hear you saying…
What I am getting is…
It seems to me…
I guess that…
I’m impressed that…
Sometimes clinicians end a statement with these questions:
Do I have it right?
What do you think?
These introductions or add-ons to an intervention seem superfluous and even counter-productive. These statements shift the focus onto the therapist and away from the client’s internal world. Consider these two formulations of the same intervention.
1. What I am getting is that you feel hurt and then you withdraw in your relationship.
2. You feel hurt and then you withdraw in your relationship.
A. In the first case, the statement asks the client to consider if the therapist is correct. The communication engenders the response from the client that “Yes you have it right.” Or “Yes that’s what I do.”
In addition, the intervention elicits intellectual-cognitive processing. At this point, the client has a subtle message to wait for the therapist, now validated, to come up with another statement. The message also suggests a subtle movement away from emotion. Often, that is not what the therapist intended to occur.
Inserting the therapist into the intervention changes the focus from uncovering, processing emotion, testing the client’s cognition distortions, or eliciting memories toward an evaluation of the therapist’s statement.
If the therapy is based mainly upon cognitive interventions, then it makes sense to move purposely to a cognitive frame. The therapist could follow with a statement of a belief, such as, “You think you should protect yourself “ or a question to elicit a belief, such as, “What makes you think you ought to withdraw rather than assert yourself?”
Nonetheless, even if the therapist intended to have a discussion on a cognitive level, I do not see the need generally to insert herself or himself into the client’s thinking. The client could have been encouraged to stay within the internal world with a statement such as, “So you can see you feel hurt and then you withdraw in your relationship.”
More specifically, the therapist who puts herself or himself into the intervention could be trying on a CONSCIOUS level to establish for the client a sense that the therapist understands or the therapist is giving merely tentative thoughts about the client’s behavior. We might make that choice for a client who tends to expect therapists not to understand or who is sensitive to criticism. In that event, however, I think it still makes sense to leave ourselves out, such as “So think this out. You appear to feel hurt and then you appear to withdraw in your relationship.”
In addition, this subtle movement to intellectualization could be the therapist’s defense against emotional or attachment intensity.
In the second example, the communication elicits a more affective response, such as “I do feel hurt. Of course I pull back.” This intervention is more likely to open an affective bridge from the current hurt to previous hurts or from the withdrawal behavior to other examples of withdrawal. This exploration may even open up a consideration of a transference event in which the behavior was similar.
We know that empathy is a crucial component of effective therapy. Putting the therapist into the intervention seems to convey less empathic connection than leaving the therapist’s self out of the statement.
Even if the therapist’s purposeful intention is to tone down the emotional intensity of the session, an empathic focus on the client ought to increase the client’s sense of being understood and the sense of a therapeutic partnership, rapport, or alliance.
Stems which keep the focus on the client could be these:
It sounds like…
So you seem to be saying…
You are saying…
What comes to mind when you feel… and then you…
When else have you….
When is the first time you…
In conclusion, most of the time, leave yourself out.
This analysis of our therapeutic use of language is an example of how therapists ought to be thoughtful and careful about how every statement, question, or intervention is framed. Everything happening in the therapeutic setting is a communication.
Everything is a statement with content, process, and meta-communication. Content is the manifest meaning of the words. Process is the pattern or sequence of communications which is understood as a whole. Meta-communication means information about the relationship between the client and therapist as expressed in their interaction. Coming back to our examples, the first statement meta-communicates that the therapist is in a more expert, superior role. Is that your intention when inserting self into statements?
Now that we have examined the implications of these statements, let’s apply our understanding to another example. In this example, the client called the therapist twice before the first appointment, both times expressing an emotional crisis and displaying emotional dys-regulation connected with events of that day. The larger context is the client is leaving a lengthy therapy in which she made little progress and is coming to see a new therapist. The referral source gave her strongly positive expectations for the new therapist. The client came with the diagnoses of Bipolar Disorder, Rapid Cycling, and Borderline Personality Disorder. Her calls suggested an insecure attachment style.
In the first session, after taking the history and assessing the symptoms, the therapist asked about the client’s difficulty with the emotional side of daily life. The data she gave included anecdotes in which people had disappointed her. The therapist wanted to establish some boundaries and to give a message about how the therapy will work. But she wanted to convey that not through rules and limits, but through empathy and work on coping. Far too often, therapists rationalize imposing limits and rules on borderline clients; but those interventions actually could create a larger breach in the client’s attachment insecurity. The therapist is going to show the client how the therapy works and how well the therapist can empathize by demonstrating it. The therapist is showing she can be there for the client rather than just promising to be there. Here are two versions of the intervention.
1. My idea about your calls is that you called me because you needed to test to see if I will be there for you when you are in distress or if I will also disappoint you.
2. You needed to test to see if I will be there for you when you are in distress or if I will also disappoint you.
A. In the first case, the words could have a subtly critical quality. The client would be determining if the therapist is correct. The statement does not convey the way in which the therapist IS there for the client.
B. In the second case, the focus is on the client’s need. Because it implies that the need is accepted, I find it more affirming of the client. The therapist is demonstrating being there for the client.
Consider this pair of interventions with the same client. The client, disappointed when the therapist was late for an appointment, shouted loudly about her needs and how no one cares about her, slammed the office door, and criticized the therapist as inept. After she sat down and toned down her reaction, the therapist intervened.
1. What I guess happened here and what I observed you doing is that even a small disappointment feels like I am not here for you and when you feel so scared by that you express all that fear as anger. I think you want to make sure I really hear it.
2. So even a small disappointment feels like I am not here for you, and when you feel so scared, you express all that fear as anger. You want to make sure I really hear it.
Statement #1 conveys a sub-text of disapproval and a message to stop the behavior. I do not think it conveys the reparative sense of being present for the client as well as does the second statement. Observation suggests these patients become better regulated emotionally through feeling empathy, reduction in attachment insecurity, and a secure transference frame.
Motivational Interviewing is a method in which leaving yourself out seems to be particularly important. When, for example, the therapist goes over the various consequences of continuing the dysfunctional behavior, it is most important for the client to experience fully the impact of those consequences. He or she must feel them as his or her own unpleasant experiences. We do not want to attenuate the experience by saying (1) “I think that getting an OWI was another painful outcome of your drinking.” A better version is (2) “So you feel that OWI is yet another painful result to you of your drinking.”
The first statement in this next pair of interventions weakens the impact of the phenomenon upon the client’s motivation to change. “It seems to me that another result of you stopping your medications is those frightening voices start up again.” “So you see that another result of you stopping your medications is those frightening voices start up again.”
So consider carefully how you assemble a statement. Are you using language as carefully as the art of treatment requires? Do you have a rationale for moving the interaction towards more cognitive or more affective processing?
© Don D Rosenberg, 2012