In this era of medical necessity and evidence-based therapies, it's easy to lose sight of the basic truth that psychotherapy is a special form of conversation: we heal not through prescriptions and procedures, but through talking and listening. Diagnoses and therapeutic models give us markers and road maps, but we have to put them into words, sentences, silences, looks, and gestures—the stuff of human interaction. However, we can get so focused on assessments and strategies that we don't pay enough attention to the core craft of our work: the spoken word. Surgeons cut and suture; therapists converse.
In workshops, I like to show a tape of a conflicted couple in which the wife, during a first-session diatribe about how emotionally distant her husband is, slips in these words: "I want my husband back." I ask the audience what they'd do next—what exactly they'd say, and to whom. Typical answers reveal a reluctance to get specific and a desire to talk strategy: "I'd try to get the wife to get in touch with her hope," or "I'd help the husband hear what his wife is saying." I keep repeating: "Whom would you address first and what words would you use?" Sometimes I have to be firm: "The floor is only open to two responses: whom and with what specific words?"
As we unpack the conversational options, it becomes clear that the outcome of the session, and perhaps of the therapy, could depend on what's said next. Nearly everyone in the room understands conceptually that the angry wife has expressed a vulnerable longing for her husband, and that the therapist's strategy should be to highlight that longing and the hope that it reflects. I break down the choices: say something to the wife or the husband, make that either a statement or a question, go cognitive or affective. Here are examples that have come from audiences:
Cognitive question to the wife: "Could you say more about what you mean when you say you want your husband back?"
Affective question to the husband: "How did you feel just now when you heard your wife say she wants you back?"
Then there are nonverbal options: for the therapist to be cool (using a calm, neutral voice, keeping the body still and relaxed) or more intense, as in my favorite response, saying softly and with emotion to the wife, "Susan, I just heard you say something that really struck me. In the midst of all the pain and hurt you feel in this marriage, you still long for Jeff. You want him back with you." The rationale here is that you want to turn up the heat on her hope before you do anything else with what she said. It'd be a mistake to ask the husband to respond before Susan goes deeper into her positive feelings for him; after all, everything else she'd just said was critical of him.
We continue the role play with ideas for how to get the husband involved in this pivotal moment. Once again, we have many options: cognitive statement or question, affective statement or question, cool or hot, having him respond to the therapist, or asking him to say something directly to his wife. It's like a basketball player leading a fast break: do you pass the ball, to whom, and at what time? Or do you take the ball to the basket yourself? In basketball and therapy, you have microseconds to decide--and your choice can have outcome-determining consequences.
Therapy as Craft
We rarely talk about therapy on the ground like this: what words at what time and with what tone and body language? Maybe we assume that if therapists are trained in good models of therapy or in the common factors of all successful therapy, they'll just know how to execute the skills. But what if we think of therapy as a conversational craft that we hone over a career with our clients and with a community of conversational healers? Crafts are traditions passed down; we learn our craft from apprenticeship with masters. Crafts have communities with standards for whether the work is done well and the product meets practical needs. Even therapists with different models can recognize good therapeutic craft when they see it, just as musicians who play different instruments or in different genres recognize good musicianship when they hear it.
So if psychotherapy is a conversational craft, not mainly a science or an art, what are the tools of the craft? They include words, gestures, statements, questions, listening, pausing, and the nonverbals that go with them. (Of course, there's a knowledge base, too, for the craft of therapy, but here I'm focusing on the tools.) Then there are metaconversational tools, such as pacing versus leading the client, heating up the conversation versus toning it down, staying with a subject versus shifting focus, keeping the conversation productive, recalibrating when the therapy is no longer productive, and using additional tools for multilateral conversations with couples, families, and groups.
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For example, heating up a conversation can take the form of using colorful and challenging metaphors. Instead of pointing out for the umpteenth time that a wife was indulging in indirect, negative communication with her husband, here's what I said: "Susan, I want to tell you what I just saw. I saw you pick up a hand grenade, calmly pull out the pin with your teeth (I mimicked the motion), and toss it into your husband's lap—and then you seemed surprised when it blew up—BANG!—and he shut down once again." The key to this being effective was the twinkle in my eye and a sense of near admiration in my voice for the offhanded artistry she showed in pulling this off. She had to laugh at herself, and I laughed with her. By contrast, I could have challenged her with more clinical (and blaming) language, such as saying something like, "That was pretty passive-aggressive, Susan," thereby bringing the wrong kind of defensive heat to the conversation. If this seems overwhelming, well, it is—for beginners. Even as an old-timer, I'm always nervous before seeing new clients, because I don't take for granted that we'll achieve a therapeutic level of conversation.
Beyond Our Natural Gifts
When it comes to deep conversation about what's most important in life, therapists are naturals. Unlike many people listening to intense emotional suffering, our instinct isn't to run or to fix. We know how to stay with pain until our client feels heard and is ready to move. If we were musicians, I'd say that most of us start out with natural good pitch, rhythm, and timbre. If we were athletes, I'd say that we can run, throw, and kick balls better than the other kids. But these natural advantages are only the thin edge of competence and far from genuine mastery. As the old saw goes, "How do you get to Carnegie Hall? Practice, practice, practice." The equivalent might be said for athletes, surgeons, potters, carpenters, architects, chefs, healers, or anybody else whose occupation requires a high degree of practical skill, along with a body of theoretical knowledge.
These experts--including therapists—don't learn how to do their craft once and for all: it's a process that continues throughout life and is never finished. Not only that, but keeping fit and staying on game means we can't continue practicing blindly, by rote, what we already know how to do. We have to stretch ourselves, make ourselves uncomfortable by practicing what we don't know how to do very well. We need to learn and repeat over and over exactly those skills that don't come naturally, that make us feel like awkward beginners. In fact, a continual willingness to begin all over again may, paradoxically, be characteristic of the acknowledged masters of any skilled practice.
Regular feedback helps us practice and learn more effectively, and it keeps us honest. We can't easily fool ourselves into thinking that it's all the client's fault when five or six others in our consulting group are telling us—nicely, we hope—just how badly we screwed up. In fact, it's just this kind of sounding board that enables us to become aware of what we aren't doing right, what we don't really know (and often don't know that we don't know). Feedback not only makes new learning possible, but contributes to one of the most important traits in a therapist, or maybe in any highly skilled craftsperson: a sense of humility and the certain knowledge that we don't have all the answers.
Other than intensive externships, where can we get feedback to improve our skills in therapeutic conversation? One approach I've been using is to ask colleagues in case consultation and other conversations what specifically they do and say in situations that lead me to have clumsy conversations or just a vague sense that there may be a better way. Here are my tips for doing this kind of craft consultation: don't ask for a case consultation, or you'll get lost in the details of the case, and bring up a challenge that cuts across cases. Then ask for actual words your colleagues use when they deal with it.
For those of us who've been in this business for a long time, the idea of therapy as a set of hard-won skills doesn't fit the glamorous vision of being a therapist we derived from watching the buccaneers of family therapy: Salvador Minuchin, Virginia Satir, Murray Bowen, Carl Whitaker, Alex Haley. It's hard now to imagine those icons of clinical starpower and shimmering self-confidence (not to mention, the even grander, more august company of the psychoanalytic masterminds of yesteryear) simply as hardworking craftspeople. Yet, there's something good and solid in the thought that no matter how much prestige any of us acquires, no matter how many clients we see, how big the workshop audiences we attract, how many books and articles we write, we still have a lot to learn. Maybe, since the glory days of the psychotherapy magic shows, we've grown up a little as a profession and as individual therapists, and gained some salutary humility about our powers in the process. Maybe by thinking of ourselves more as craftspeople on a noble but futile quest for perfection, we're becoming better therapists, even as we demystify the glamorous idols of therapy.
William Doherty, PhD, is a professor and director of the Minnesota Couples on the Brink Project and the Citizen Professional Center at the University of Minnesota. He is founder of Citizen Therapists for Democracy. His books include Helping Couples on the Brink of Divorce (with Steven Harris) and Medical Family Therapy (with Susan McDaniel and Jeri Hepworth).
This blog is excerpted from "One Brick at a Time" by William Doherty. The full version is available in the September/October 2012 issue, The Craft of Conversation: Kindling the Spark of Therapeutic Change.
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Topic: Professional Development
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