Johnella Bird's Therapeutic Strategies: Talk that is felt, talk that sings

 

Introduction

Johnella provides therapeutic strategies to enable talk which appears ordinary but is felt to be transformational.

Like the perfect golf swing or tennis shot, this work has a deceptive simplicity and lack of apparent effort when well executed, a difference from other conversation. This difference is 'felt rather than heard'.

We (Tania and Josephine) found what we learnt from her so transformed our work that we developed the precursor to this website to make the practical strategies she has developed available as widely as possible; albeit in a simplified form as we understand them. Much more depth and sophistication are available from her books, DVDs and website; see her website heartsnarrative.

The focus is engaging the person in joint discovery. We bring the professional and personal knowledge and experience we hold. We use skills in listening and structuring a conversation to bring forward the knowledge, experience, values, intentions, emotions and thoughts the person has so they are available to the discovery process.

The conversation is structured to enable the person to experience movement, from being 'in' their experience to moving 'out' to a reflective stance, a mountain top view, looking in on their experience. The purpose of this is to enable them to experience movement, engage with the experience they have in a different way, to experience discovery.

In the role of therapist we need to be present, listening carefully with openness to what we hear. At every moment the focus for the conversation is on the person's agency and resources, hearing them, naming them, inquiring further about them and including them in summaries of the threads of the conversation. Agency is seen in strategies people are using eg being hypervigilant, keeping out of sight, distracting themselves, working long hours, striving for perfectionism, shutting off their feelings or many others. A person's resources might include intentions or values they hold, experience they can draw on or capacity to imagine.

These skills can be used in any conversation with one person or with many. For easier flow we have talked as if there is one person but these strategies work very well with families or other groups.

At times we have spoken about our work. Mostly these are micro examples of types of conversations we might use in different forms with different people. Where we have had a specific person or family come to mind we have shifted the detail to include other examples and change or remove any detail which would allow identification, even by the person themselves. The videos we have included were specifically developed as role plays for use in teaching and we have re-sought permission from the people involved to use them on this website.

 

Getting started

This approach to therapeutic conversation is profoundly counter cultural and trying to change midstream can be discombobulating. In the moment in a clinical conversation we need to be present in the process, responding with spontaneity.

Begin by noticing opportunities to have done something different with the conversation. Rehearse different possibilities out of session. This is what a tennis player might do if making a change to their approach to doing a serve.

Try some of these practical strategies. They can only be useful to the extent to which we are able to listen for, and hear, what we are not expecting.

Be sure you are hearing and understanding what is said. We can make this clear that interrupting the flow is because it matters to us to hear and understand what they are saying:

"I need to stop you and slow down the conversation. What you are saying is really important and I want to be sure I am getting it."

Focus on what the person did or is doing, how they approached the situation. In response to trauma or difficulty, instead of empathising and dropping the person further into their distressing experience try focusing on agency:

"How did you get through?"
"What kept you going?"

Telling is a strategy with limited effectiveness. This is why we have begun with some ways to get started. We can tell about how good this approach is. But if we can engage the reader in trying some strategies which seem to make a difference, however small, this is worth a world of telling.

We can't write a website of questions but in clinical work they can be a lot more effective than telling. So, when you are wanting to offer a recommendation, or feel as if you hold some knowledge about the best choice a person could make, try framing it as a question.

"What would happen if you …"
"Do you think it would help if you …"

Negotiating content of conversation can be done very simply, and demonstrates in interest in and respect for the autonomy and resource of the person. It is surprisingly effective and surprisingly difficult to remember to do:

"Are we talking about what is most important/useful/interesting to you?"

When we are telling the person things which we believe are valuable for them, we often check in, perhaps saying, "Does this make sense?" The intention of this question is important but it may not be easy to answer, particularly in the context of the power relation. Try:

"What are you noticing in your thoughts and feelings as I am talking?"

Sometimes we are so busy categorising, building theories and checking them out that we end up with only a superficial and general understanding of what the person is experiencing. Ask yourself and listen to your own answer:

"How well do I understand what this experience is like for this person?"
"What would help to increase the understanding I have?"

 

Relational languaging

Totalising language is the prevailing language form used in everyday and professional discourse. For example, I am clever, dumb, sad, violent, happy, confident, depressed. The structure of the sentence identifies the person with the problem. There is an implication that these descriptions represent static attributes of a person who is defined by them.

Traditional externalizing is a linguistic strategy developed by White and Epston. 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 inquiries such as:

"What sort of effect does depression have on your life?"
"How often is this hitting happening? Have you tried to stop the hitting?"
"How can mum and dad support you in standing up to the OCD when it is tricking you that you need to shower till all the hot water is gone?"

Rather than the person being the problem, the problem becomes the problem. It is particularly useful with a specific issue and for younger children. As a linguistic strategy it allows the parents, the clinician and the child to unite as a team to address the problem.

However, where the issues people are struggling with are very pervasive they can be difficult to separate and place outside self. Traditional externalizing of a generalized idea, such as perfectionism, OCD or Anorexia can be quite distant from the person's experience. Even when identified out of the person's experience once an externalized issue becomes developed it can 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.

The person is placed in the sentence as active in experiencing or displaying the issue.

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

The focus with relational externalizing is to explore the person's specific experience. The person's response needs to be listened to carefully, with consideration for shifting or changing the metaphor.

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 some confidence, 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.

Relational externalizing enables the person to look in on themselves in relation to the issue. The difference between this and ordinary language is felt, rather than heard. It creates space between the person and the problem, but maintains a relational connection. Rather than being separated from the person it puts the feeling or idea in relation to the person.

By reflecting a person's experience in relational language when they are immersed in it we can enable them to experience the movement from being 'in' the experience towards being outside, reflecting on it.

The person has the opportunity to experience themselves as an active 'I' having the experience; "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?"

It supports contextualising, understanding an experience in terms of multiple influences around the person, rather than something which arises out of a defect in them.

We can talk about:

"the anger/low mood/loss of confidence you experienced when …"

We might ask about:

"What are some of the situations where you have noticed the lying happening?",

Talking about lying which is noticed when …, provides an opening to understanding the lying and an implication that there are times when the lying doesn't happen.

It opens space to soften all or nothing thinking, to move out of binary.

Compare:

"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?"

 

Using what we are noticing in the present moment

What is happening in the room is alive with possibility for movement and discovery. In observing the person we may notice something has changed. Feelings and body responses are important and we need to know what it is that has contributed to that response. It could be completely different from what we expect. Describing what we have noticed in tentative relational language can enable the person to have an experience of movement from being 'in' the experience to being 'outside' in a reflection (hilltop) position. It can also put us in an observer position.

For example:

"Can you put words to that anxiety/tears, etc? What was I saying when you started to become aware of it?"
"I noticed as I asked that question there seemed to be a lot of thought. What was the effect of the question?"
"I felt so angry when he came back late." "Can you describe this anger you felt."
"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?"

A common response to feeling as if a conversation is not working very well is to try harder. This may help but is high risk if we do not understand what the person is experiencing or thinking. We need to explore the response we notice in tentative relational language.

"This is what I am noticing (e.g. sighing, lots of looking at watch). Have you noticed this as well?" "I am wondering if the conversation is not working for you."
"It seems as if I have got more energy in this conversation than you do."
"Is there any sense that there could be a trick happening here, that I could be tricking you?"
"I am noticing you being very still and what looks to me like some tension in your face. I am wondering if some feelings are coming up for you, feelings like frustration, irritation or even anger." "What are you noticing?"

This has the potential transform an unhelpful conversation as well as offering the person an experience of movement from being in the experience to noticing and naming it. They may also experience agency in being supported to address their concerns. It provides a rich opportunity for discovery.

Noticing a response we experience can alert us that something important is happening in the room. This awareness might not be available in our conscious, cognitive processing. We need to notice the experience in relational language and hold our response. We cannot always manage to respond constructively in the present moment and it may be that we need to put it aside and explore it in relational language out of session or in supervision.

It may be useful to slow the conversation down, gather threads, consult with the person regarding direction and consider the effect of the response we are having on the conversation. It is particularly important that we do not consider it a failure if we experience feelings of anger, irritation, frustration, boredom, being hopeless or useless or wanting people to never come back ever again. It is a failure of looking after the relationship if we do not take that to supervision or somewhere else and say, 'this is what I experienced, let's make sense of this'.

Feeling bored with a situation can mean we are making an assumption or are ahead of people, trying to get to a place that is safe and better but not working with what is right now. It is important to check this out.

"I'd like to stop the conversation for a moment. I just want to check how well this conversation is working for you." "I am wondering if there is a bit of a clash between us. Are you noticing anything like that?"

We can be immobilised when we experience judgment because we are aware it is not a helpful response. However, there may be something important happening. By silencing ourselves we miss an opportunity an opportunity to explore it. Communicating judgement is not likely to be helpful, but exploration may well generate some useful discoveries. Try, using a tone of voice and demeanour indicating interest rather than judgment:

"How did you make that decision?"
"How well does that work for you?"
"What were you hoping when you …?"
"I noticed you spoke quite quickly and strongly in response to what Mary said. Is that what it seemed like to you?" "Were there some feelings you experienced?" "Can you describe them?"

 

Inquiry with a discovery orientation

In a collaborative discovery conversation we combine our learnings from the conversation so far with our clinical and personal knowledge to inform an inquiry and listen carefully for the answer. We need focussed presence with openness to an answer we don't expect, an answer which disconfirms our ideas.

Engaging people in a discovery process is key to addressing the power relation inherent in a therapeutic relationship. We are at risk of subjecting people to our ideas of what we think is happening in their minds, or even dominant cultural ideas we might carry ourselves. Collaborative discovery conversations provide a technology for coming up with meanings, ideas and understandings people own, rather than offering ways of understanding. We are listening for an opportunity to explore rather than to confirm our ideas or categorise.

We tend to think of the purpose of asking a question to be to elicit information, to make information held by the other person available to us. This is often the case as in:

"How much are the apples?"
"What is the best oil to use for my car?"
"Where do I find the Post Office?"
"Where are you feeling the pain?"

But what of a question like, 'How do you do?' or even the more informal 'How are you?' They can be automatic responses not seeking information at all.

'What are you looking at?' or 'Who do you think you are?' asked in a mildly hostile tone may be intended to intimidate.

Questions seeking information are not neutral. When I meet a friend who asks me how my children are going I experience this as an indication of the interest and care they feel for me and my family.

When I (Josephine) went to a university in a new city many people asked me the same three questions: What school did you go to, what suburb does your family live in? and what does your father do? I did not experience them as interested in me, but wanting to categorise me according to a social scale.

When we go to the doctor with a physical health problem they ask us about the troubling symptoms we have been having in order to gain information to make a diagnosis of a problem they can help with and come up with some treatment ideas.

When my children were little I (Josephine) had a friend whose children were a bit older than mine. I would often ask her things like: "What did you do about pocket money?" "How would you decide if the children could go and stay over with someone?" The purpose of these questions was to elicit information, information which I thought might help me in my decisions. The conversation was based in the respect I had for the parenting I saw this woman doing. It struck me one day, in a clinical interview, that my questions were focused totally differently. I was looking for what parents were doing wrong, gaps in their parenting strategies that I could fill.

Questions are constructed to place the person in a collaborative position as someone with resource and provide an opportunity for movement to open space in their thinking and emotional experience.

Assessment questions seeking deficit based formulations can be experienced as pathologizing. If we can ask with a discovery orientation, with profound respectfulness for the knowledge the person holds, seeking to elicit resource which will help us move forward, we can engage the person in a constructive discovery conversation about almost anything. We want people to experience the questions we ask as invitations into a process of joint discovery, an indication of the respect we hold for them and value we place on the knowledge and resources they hold.

"Is the strength of the anger you feel when your daughter self-harms an indication of the depth of the love you feel for her and the commitment you have to her safety?"

[To a parent who is lecturing his son] "What are you hoping he will take from this conversation?"

"How did you make that decision?"

When we just encourage a person to talk they can feel some relief and may feel listened to but there is limited room for discovery because they are just telling us what they know. The purpose of discovery focused inquiry is to bring forward the person's resources into their conscious cognitive awareness so they have access to them. Resources can include sensory/emotional experiences, memories, intentions and values.
The intention is to develop discoveries the person can own. They won't hear the skills we use to get there. An indication that a discovery process is happening is people coming out with thoughts like:

"I didn't know I knew that."
"I hadn't thought of it that way"
"I didn't remember that, isn't that interesting?"

A red flag to indicate we have moved out of collaborative discovery mode is a clinician saying, "does that make sense?"

 

Carefully constructed inquiry

It takes considerable clinician focus and skill to construct a useful, easy to answer question. We often find, as we hear ourselves ask a question, that we need to rephrase it. This is not a fast paced process like banter. As clinicians we need to slow the conversation down to give ourselves time to develop a helpful question and give the person time for processing.

Open questions give people a lot of space but take more mental effort to answer.

A question like:

"How are you finding this conversation?"

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

"I notice you are looking down and shifting in your seat. I am wondering if you are finding this conversation a bit uncomfortable." "If you were starting to find it uncomfortable or uninteresting how easy would it be for you to let me know? Would it be really easy, middling, hard or more like impossible?"

Questions that are not too big are often more helpful. For example, compare:

"What has changed?"

with:

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

Making questions particular and practical is helpful:

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

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."

This is an example of a long, complex inquiry using clinician knowledge expressed tentatively and offering alternatives.

"Thank you for letting me know that you don't want to talk about the things which have been troubling you. I would like to understand more about this decision. Would you be OK to help me understand the decision if we are clear there is no pressure to talk about them?"
"If you started to feel pressure to talk about them what would I notice? Would you be able to let me know?"
"I could tell you some of the worries other young people have said make them reluctant to talk about tough stuff." "Would you like to hear about them?"

"Some people express a concern about confidentiality, who else I might tell. Some people say that they cannot find the words to describe their experience. Some people describe a concern that I might judge them or think less of them. Some people say that keeping these things out of their mind helps them get through and if they talk to me about them that will bring them into their mind and they will experience feelings which will make them feel worse. Is any of those even a little bit true for you?"

The young person has a lot better chance of forming an answer to a question like this than a simple inquiry, "why" or "How did you make that decision not to speak about what is troubling you?" If they endorse any or all of the alternatives this offers possibilities for further discovery.

 

Gathering threads

There is an Arabian proverb describing a friend:

"A friend is one to whom one may pour out all the contents of one's heart, chaff and grain together, knowing that the gentlest of hands will take and sift it, keep what is worth keeping and with a breath of kindness blow the rest away."

This is an essential component to a therapeutic conversation. But in a therapeutic conversation we are going beyond the role of a friend. We are actively structuring the conversation to bring forward the grains. We focus the listening we do on agency, knowledge and resource, including intentions and values. In gathering the threads we pause and reflect back a summary of what we have noticed in relational language. Where possible we use the person's own words.

This is a process of raranga or weaving to create a kete, a bag which has strength far in excess of that of any individual strand of flax from which it is made.

It can be affirming and centring for the person to hear what has been discovered spoken by the 'expert' in the room, particularly if we use their own words. (This needs careful notetaking.) It slows the conversation down, giving time to reflect for us and the other person. It gives an opportunity to consult.

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 with 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."

Bringing together themes mentioned earlier in the conversation with those mentioned later gives an opportunity to make movement and difference explicit as part of the discovery process. Plaiting may contribute but we are weaving, not just plaiting.

"We started the conversation with an intention to focus on the relationship between the two of you. We moved the focus to the concerns you both have about your daughter. Then we have started talking about the concerns you have about the school. I am wondering how the issues are connected or affect each other."

We cannot focus on everything, but it is important to encourage the person to choose where we put the emphasis.

"Our conversation has ranged over several aspects of the life you are living. You have talked about the experiences of being bullied at work, of frustration with your partner, of wanting to spend more time with your older children. Which of these is most interesting to you for us to focus on?"

We also need to manage the risk for us of attending to the last thing the person said and for the person to remember only the last 10 minutes of the conversation. Throughout the whole conversation we need to be weaving the threads we are discovering together. We are setting out to build a narrative centralising their agency and resource. This narrative is located in context, time in history, experiences, family, social context and personal events in order to make sense of the person's actions and create a platform for movement.

If we are successful in engaging someone in a joint discovery process focusing on resource and agency with an experience of movement from being 'in' their experience to being 'outside' reflecting, they are likely to notice feeling a bit lighter, feel they have had an experience of being listened to and feel we are nice, understanding people. However, this doesn't take them far.

People need support to take away the complexity of the narrative we have been building or it risks being lost. They need support to be able to hold the sense of the discoveries they have made so it can create a platform for movement.

Options include: a piece of paper used during the conversation to record the threads as they come up, a clinical note they have a copy of, a voice recording, a clinical letter or a specific 'therapeutic' letter.

 

Explicitly negotiating safety in the therapeutic relationship

Engaging the person as an active partner in the discovery process around managing safety and building trust can be therapeutic in itself. It gives an opportunity for the person to experience someone holding power in the relationship asking about and listening carefully to their experiences. Carefully constructed inquiry can enable them to take up agency in the context of this power relation.

"You have described some experiences you have had in therapy where you ended up feeling an increase in sadness. I am wondering if it will be possible for you to let me know if we were starting to move into talk where that might happen. What would be the first sign you might notice?" "What would I see you do if that was starting to happen?" "Would you be able to let me know, give me a sign?" "If I thought I noticed something and asked you, would you give me an honest answer or might you pretend things were OK?"

Levels and forms of safety and trust are present in every relationship. Explicit negotiation in this relationship has the potential to bring knowledge and experience the person has into their conscious cognitive awareness. The explicit awareness of this knowledge increses the possibility it will be available to them in any relationship they engage in. For example:

"I notice you looking down and away. I am wondering if you are feeling some discomfort in the conversation." If endorsed. "I am wondering if you would have been able to let me know if I had not asked directly." What would have influenced the decision you would have made about whether to tell me or not?"

This has the potential to bring forward strategies the person uses widely in relationships, such as conflict avoiding and people pleasing, which they have developed in a context of fear. They can then be explored.

Safety is dynamic, a relational construct, in a context. When people experience lack of safety in a moment the risk is that they experience this as evidence of a deficit in themselves, eg too sensitive, unable to connect to people, no good at talking or so damaged or incompetent they cannot be helped.

If we notice a drop in tone, change in body posture, struggle to speak or change in emotional presence we need to check this out. We need to look for a way to move forward and return to the concern later to check out if we are making progress.

"What were we doing when this happened?" "How can I support you now?" "If we were to increase the sense of safety in this room what would we need to do?"

 

Carefully negotiating meaning

What a person says about their life it is as close as they can get to the experience, it is not the experience. When I tell you about sadness I am experiencing you make sense of it in terms of experiences you have of what you call sadness, what you have heard from others and other sorts of knowledge you have of sadness. All of this may bring you somewhere near getting an understanding of what I am experiencing. But we cannot afford to take it for granted.

Because of the power relation in a therapy situation people are likely to see our knowledge and understanding as superior to theirs. When we pick up meaning in a way they do not intend there is a risk that they will value our knowledge over theirs and conclude that what we say 'must be true'. They are at risk of discounting their experience in favour of what they perceive as ours.

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.

Making an inquiry in relational language about what a person is experiencing in the present moment is an opportunity for more specific understanding of meaning in context.

"This jealousy that you were experiencing as Mary said this and this, could you put words to this jealousy."

What is important in this conversation is not some sort of general jealousy, it is this jealousy in this moment in relationship to this person.

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?"

Exploring how an idea is expressed in action or the intention, values and hopes associated with an action can bring out meaning. 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 how can she express that in a way which shows respect?"

"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?"

Meaning making is spiral like. It appears as if we are coming back to the same place but we are not. You experience it, you research it and shift what you know of it, then research that.

 

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.

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

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

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 example:

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

 

Moving out of binary

A binary allows only two positions. There is little joy in being positioned on the negative side of a binary. But being positioned on the positive side of a binary is precarious. For example, holding a view of myself as a good, rather than bad, clinician places me at risk of slipping into the role of being a bad clinician if I notice even a small flaw in my practice. However, the knowledge that I have certain skills, values, knowledge and experience, I use regularly is not affected by my becoming aware of a situation where my practice was not what I would have wished. I do not have to let go of my positioning myself as a good clinician. I can hold my appreciation of what I value in my practice and explore how I can do better.

With someone who has been assessed as unfit to parent one might ask:

"Is there anything good enough about the parenting that you do that [child protection agency] hasn't noticed?"

Relational languaging facilitates moving out of binary. "I am hopeless" can be moved into:

"When you act on patterns you have learned to support a high level of achievement you sometimes find yourself taking on more than you can manage. In those times of trying to achieve the impossible you find yourself falling short of the standards you hold and experience an intense disappointment in what you are able to achieve."

Moving out of binary facilitates negotiating engagement. We need not be limited to considering having or not having trust. There might be beginning trust, fragile trust, or we can talk about the process of developing trust. Similarly with anxiety. We can talk about 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.

 

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 treated each sensory input as unique we would not be able to function. But this means 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 example:

"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. Specificity and detail are needed

"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

We tend to be drawn to the lack. Our professional training and literature also often focus on deficit. We are presented with concern about a lack of self esteem, confidence, respect, etc Focus on presence rather than absence is more conducive to optimism and movement. We can invite the person to use their imagination to bring forward the ideas they have about the present. For example:

"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?"

 

Our skills may not be noticed

What we are working towards is not for the person to leave the session thinking how clever and skilled we are and how lucky they are to have met us because they wouldn't have managed without us. The focus is to bring into conscious awareness the skills, knowledge and resource they have. We want them to own the discoveries and shifts in thinking and awareness we have made together. People are likely to find us helpful and feel listened to. They will often appreciate the conversations and what they get from them but won't hear the skills we use to get there.

I (Josephine) had an example demonstrating this when I was asked to see a mother of two children with special needs who was experiencing and expressing anger and disappointment with our service. She had good reason and there had been some unhelpful conversations. I worked hard maintain my focus and presence in using Johnella's strategies described here.

Focusing on agency and resource was straightforward. She showed a sophisticated understanding of her children's needs and advocated for them with passion. She parented tirelessly and skilfully herself. I took careful notes and was able to gather threads in relational language using her words. Working in the present moment by noticing body changes enabled her to put words to some of the losses and grief she was experiencing in the context of the love she felt for these children for whom so little was being provided. Listening carefully and hearing some things which surprised me I found the conversation much more interesting than I had expected.

We reached a point where the clinician I was with and I were able to make an apology she could accept. We began a practical collaborative conversation about the limited ways in which our service might be able to provide something which would be useful for the family. I found the conversation very moving and felt drawn towards this woman in her challenges. She expressed appreciation for the conversation.

After the interview the clinician who had been with me turned to me and said, 'It wasn't so hard, was it?' He had observed conversation which appeared ordinary, but which transformed without noticing the skill and focus involved.