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How Conversation Sparks Therapeutic Change - Page 2

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Of course, all good therapists do just talk with clients to some degree--it's really the lifeblood of therapy. But as a field, we've been unconscious of the nature of the conversation that energizes our models and techniques. It's as if the craft of conversation were a secret weapon many of us have, but aren't allowed to acknowledge, much less consciously work at improving. Yet, without it, treatment can be a textbook exercise lacking the power to make clients feel a truly alive and personal connection with their therapist. After all, we converse to get beyond categories and stereotypes to discover a person's unspoken self beneath the social mask.

I began to pick up this basic truth by noticing that something remarkable happened when therapists went off-script and managed to squeeze in genuine conversation between techniques. I remember one of my fellow interns who started sessions with, "So who's your favorite baseball team?" or "Where do you like to shop?" Then he'd proceed to get into heated debates about whether the Mets or the Yankees were better, or whether Macy's or Loehmann's had the best bargains. He was, of course, eviscerated for his "unprofessional" behavior by every supervisor who could be rounded up to stamp it out. But here's what I also noticed: his patients opened up in therapy, while about half of the patients seeing more formalistic therapists remained closed off.

I finally realized how conversation could turn into something unexpected and deeply therapeutic when working with a supervisor on a locked ward. One of the men had become paralyzed from an accident he'd had during a psychotic episode and awoke in the psychiatric hospital still psychotic and now permanently immobile from the waist down. As time moved on and he felt slightly less depressed, a female friend from his neighborhood started visiting him. The two got closer, became "an item," and within two weeks announced to everyone that they were getting married. Nobody knew how to slow down this romance because most of us were stuck in our diagnostic categories, clinical protocols, and standard therapy-speak. As a result, the situation was accelerating before our eyes and we were helpless to stop it.

During a session with this man and his intended, with my supervisor present, I ever-so-sensitively asked them "How does this make you feel?" in every permutation I could imagine. I hoped in this way to get to their deeper motivation and create some "observing ego." My supervisor mercifully broke in and began a casual discussion with the man's fiancé about cooking, of all things. Finally after going over some of the best ways to throw together a meal, he asked her, "By the way, what do you plan to cook for John when you get married? What are his favorite dishes?"

"Well, lamb chops, of course," she answered.

John looked at her perplexed, and said with a slight edge to his voice, "No, my favorite is pasta."

Then the supervisor began to talk with John about sports he could still do, such as fishing, as well as some other activities they discovered they both enjoyed. I was becoming impatient, imagining myself being buzzed out of the room if I'd ever wasted this much time.

My supervisor then asked John, "So, when's Mary's birthday? I understand it's coming up soon. What are you thinking of getting her?"

John mumbled something about a fishing rod.

Mary looked at him baffled, and said, "Are you crazy? I have no interest in fishing whatsoever!"

They looked at each other as if they'd just met. After some hemming and hawing, John said, "You know, I don't think you understand me very well."

Mary replied, "Well, likewise about you! Look, maybe we should think about this some more. And besides, my parents aren't wild about the idea, either!"

All of a sudden the two were immersed in an intense discussion about whether they knew each other well enough to get married at that point--a conversation that then widened into how their respective families were reacting to these developments, and finally a plan to get to know each other a bit better before tying the knot.

I was stunned to see such a powerful outcome from such unscripted dialogue. I understood there was a kind of subliminal point to what my supervisor had been doing. Still, even if his mission had been to stop the marriage, he took his time to create a discussion with these two people and find out who they were. In that process, he elicited each one's unspoken self, revealing their personal truths.

The Rise of Protocolized Psychotherapy

Such unexpected moments of learning were soon overshadowed by tectonic changes in the field and culture, however. To paraphrase a Terminator movie, the '90s brought "the rise of the machines," a revolutionary emergence of protocol-driven interventions for both adults and kids. Guided by symptom checklists and monetized by the insurance industry, all of these protocols underplayed conversation. Each new approach was extremely valuable, though, and allowed us to craft personalized models along the way. My own is a synthesis of psychoanalytic relational, structural, and family systems approaches, with elements of cognitive-behavioral therapy, dialectical behavior therapy, and attachment theory. Yet, there remained a suspicion that something integral to the way people connect--the way we discover the other and ourselves--was still missing in therapy.

In fact, the more I spoke to and consulted with therapists from diverse clinical perspectives, the more I became convinced that the "in-betweens" of official treatment are at the core of therapy. Above and below, within and around the protocols--from psychoanalysis to EMDR--therapists talk with clients in ways that human beings have always talked when they want to establish a real connection. They speak like people, rather than approaches. Not surprisingly, given our training in all schools of therapy, this form of casual-speak is a cause for some embarrassment among members of our profession. So we widely practice a kind of double-bookkeeping, as one of my early mentors described it to me: "What we tell our teachers and supervisors we do and what we really do in the consulting room are two different things."

We talk a great deal about the importance of relationship and connection in therapy--the "therapeutic alliance--but what this really comes down to is the everyday miracle we call conversation: the unscripted exchanges we treasure from our friendships and romances. But does this mean that, as therapists, all we need to do is hang loose and let go? Are there any "rules" for therapeutic conversation? The danger of this question, of course, is in the implication that there might actually be an entire "model" here. But if there were, it wouldn't be conversation anymore, just another unvarying set of clinical steps to get from point A to point B.

For a trained therapist comfortable in his/her professional skin, however, there is indeed a craft to making good conversation, which does have a purpose beyond simply passing time. It must generate an atmosphere conducive to doing the clinical work at hand--which means there's an overarching, if not exactly specific, direction to it. The Zenlike paradox of therapeutic conversation is this: an exchange with no purpose other than the interaction itself can guide us exactly to where we need to go in treatment--to the unspoken self of the person sitting across from us. But how do we get started?

I think we make use of what I call "crafted spontaneity," which means that if we follow whatever infinitesimal signals of life the patient emits and the life happening inside ourselves, we might have an unexpected encounter outside the framework of a specific therapy model. If we accept uncertainty and create conversations that lead to the client's experiencing his or her unspoken self in the therapy relationship, this can change a client's behavior, self-concept, and life story.

So, how do we do this? Over the years as both a therapist and supervisor, I've nurtured the unpredictable with hundreds of clients and listened to sessions as recounted by hundreds of other therapists. As a result, I've begun to see guidelines for the sometimes paradoxical craft of spontaneous therapeutic conversation.

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