Learner therapist (22)……Telling people what they “need” to hear

Learner therapist (22)……Telling people what they "need" to hear
Torrey Orton
Sept. 9, 2012

"What you need to do is…"

A friend challenged me a while back with the proposition that "you can't tell someone something they don't want to hear". So I started on the spot (at the time in an Art Nouveau café/bistro frequented by Collette in Besancon, France in the early 1900's) to demonstrate how I could do that. My first move was to contradict her assertion, which got her attention, so to speak…the rest I want to explore somewhat more systematically as an approach to patient education / awareness in therapy.
The methods / techniques of confronting must vary with the vulnerability of the patient, the therapist and the present state of the therapy relationship. The principle form of variation is the intensity of the truth claim made for the conflicting opinion on offer from the therapist. Truth intensity is expressed, apart from non-verbal components (volume, pace, gesture) by choice of modal verbs – could, should, must, might – and the level of truth claim: e.g. I guess, I suppose, I imagine, I believe, I'm sure, it is the case that, and so on…ascending to scriptural or other canonical claims of irrefutability.
Variable vulnerabilities
These variations are the 'how' of telling someone what they do (may!) not want to hear and are more important than the 'what'. The what provides the conscious motive for taking action. There are three easily assessed and communicated whats: (a) a patient's emotional misalignment with their present concerns, (b) a misapprehension of what's happening – the facts, and (c) inappropriate beliefs or values for dealing with their concerns about what's happening.
On the whole, the success of any effort to tell somebody something against their immediate sense of need for an offer will fail, no matter how relevant, shapely, timely the offered information is. This is because the offer has to be perceived as an offer of help; that is, as arising from the therapist's positive intent towards the patient. This is the primary motivation of an offer, not the 'what'. If positive intent is in short supply or at the time not in view, then the patient will perceive the offer as a preface to a manipulation and back off as much as they can.
Don't ease in
This fact is the background to the idea that a difficult conversation can never be "eased into" successfully. The effort to ease in will be perceived as what it is – not the real message, just making small talk when big talk is expected and necessary. Rather, the patient will perceive a cover-up, a deception, occurring. Therein lies the undisclosed vulnerability of the easing-in therapist, signalling the therapist's doubt about containing the consequences of the confrontation. Doubt is what patients already have plenty of themselves.
The overall aim of therapy I understand to be the building of a conversation which is a normal, effective adult conversation with appropriate turn-taking, etc. I give patients various kinds of evidence which they can use to test whether they are getting better, and to mark eventually that they are finished with our work. One kind of evidence has to do with jointly conducting the agenda and process of our therapeutic conversations.
A simple, learnable system for effective therapeutic conversation is the three step chunking device of Entry, Action and Close with Checking for effectiveness at each step along the way. This system is a means of engaging any kind of actually or probably or possibly conflictful context. For example, see The Negotiator (1998) for an extended example of walking along the fringe of violence without either denying its possibility or falling into it (a fantasy we may have about all perceived conflicts). Every time one side or the other picks up the phone to initiate a call a new entry has to be created by the person calling. This is often pro-forma, but if matters are emotionally dense, for whatever reasons, some attention must be paid to details like acknowledging the existing feelings.
The whats of therapy
Back to the whats mentioned earlier. I'm going to focus on confronting patients about (a) their personal (in)congruence, (b) their (mis)understanding of "the facts" and (c) the beliefs (including values) through which they interpret the world. These are the 'what' of confronting, the reasons I would want to confront a patient – that they do not know what they feel, that they do not have the facts in hand and/or that they hold incorrect beliefs about the world (and so miss some of the facts).
The system in brief – a short example
This example will show a different what in action in each step and the movement from one step to another through engaging the whats of the discussion. This is merely a sketch. Each chunk might take more time to work through.
Entry
– the entry step seeks to make reliable contact with the other person, set a notional agenda for mutual attention and make the first move into the action step; it establishes the imagined interaction's purpose, process and outcome.

1. their personal (in)congruence:
   X had been talking about his childhood abuse by a family friend in a calm and fluent manner with lots of detail about time, place and action. We'd been working around his anger and overpowering anxieties for some weeks when this story came up. It was almost scripted. Subsequently it turned out he'd told the story to other therapists and a psychiatrist without the feeling of the event getting through, nor being asked for.

After few minutes I said:

I'm not sure where you're going with this, why it's important to you…your expression is a bit blank but the story is a major trauma. Can you tell me what you're feeling now?

Check* - Does it feel right to look into this now?
Action – action is where the work proposed in the entry gets done, or at least attempted;
to continue this example:

1. (mis)understanding of "the facts"
   X identifies a little distress after telling the story because he's not too sure if what he said is true, if it really happened exactly as he said…maybe even it didn't really happen?? No one else who knew it happened has talked about it– not his grandmother, nor his parents, even to this day 30+ years later. (This family silence becomes the near source of his continuing trauma, the engine of repeated doubt and anxiety of catastrophic proportions.)

So I said,

No, you're wrong about that. Memory works like this…. Memory is never perfect. In addition, your difficulty with the fact of memory's fallibility is magnified by your family rule against exploring it, which among other things may makes you feel it is wrong of you to want to clarify the memories….we've talked about your parents active resistance to such exploration often over the last months….

Check* - Is this matter clearer than it was at the start?

Close
– is when a clear end to the action is achieved, for the moment. Possibly a new entry is proposed either immediately or at some specific time / place in the future. Doing so provides continuity and, more important, evidence of commitment to the relationship (appearing above as "positive intent").
Finally X said,

1. the beliefs (including values) through which they interpret the world –
   Yes, it's clearer and I think I now see that expecting perfect facts is one way I hold myself to ransom with my fallibility and guilt…it's hard to see clearly, but that abuse was not my fault...I'm caught in a system of denial…

And I replied,

So maybe we can look more deeply at how that system is spread throughout your life, not just your family of origin…

Check* - Is what we've done so far moving in the direction(s) you want, need…?


There's a start on telling people things they may not want to hear. There's a host of fine points for different situations, vulnerabilities and relationship statuses. You may have noticed that Checking could have the result of stopping a step in its tracks and forcing a return to the previous one. That's the price of effective communication. Knowing that itself can help bridge steps which feel like they are moving back more often than forward. I've been working with X about this for 18 months.
Maybe next round I'll provide a few extended vignettes of confrontations which have been extremely high volatility and also resonating effectiveness for their participants…both me and them.

*Checking is a sub-step throughout usually made by the therapist to ensure a good fit of process and content is maintained. Patients can be expected over time to provide checking themselves, too. It should prevent misunderstandings or misinterpretations, and consequently reduce unintended deceptions both ways. For each of the three domains of confrontation ask things like:

(a) their personal (in)congruence,- How does this feel to you now? How's your breathing, tightness now?

(b) (mis)understanding of "the facts" - Is this matter clearer than it was at the start? What do you see as the key facts in your struggle now?

(c) the beliefs (including values) through which they interpret the world - Is what we're doing now moving in the direction(s) you want, need…?