Therapy Talk

Conversation Analysis in Practice

P. Fitzgerald

• Publisher: Palgrave Macmillan
• Year: 2013
• ISBN:
  9781137329530
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Therapy Talk aims to help those who apply 'the talking cure' become better at their jobs by enabling them to understand how their verbal responses may channel the conversation partner into a particular direction, promoting conversation analysis as a useful tool to study and enhance the therapeutic alliance between client and practitioner.

1

Introduction

Background to therapy talk

This book, like many others before it, focuses on the business of psychotherapy and counselling which are known nowadays, in professional as well as lay circles, as ‘the talking cure’. The invention of these practices is greatly associated with Breuer’s work in the late nineteenth century with a patient of his, known as Anna O, who coined the phrase. Anna was diagnosed with hysteria and suffered many physical symptoms such as paralysis, aphasia, neuralgia and amnesia. In her case study she described how she experienced relief from her symptoms, distresses and concerns by verbalizing them and coming to understand their origins (see Freud and Breuer’s Studies on Hysteria, 1991 [1895]). Since the time of Breuer, Freud and Anna O, several modifications have taken place within the field of psychotherapy. The past century has witnessed the evolvement of over four hundred different theories, clinical models and techniques, which encompass the field of psychotherapy today (Orlinsky and Howard, 1995; Norcross and Goldfried, 2005; Roth and Fonagy, 2005). These developments also include variants on the concepts, theories and techniques of the major psychotherapeutic approaches such as psychoanalysis, the humanistic therapies and cognitive-behavioural therapies. In fact, there seems to be so much diversity and so many subdivisions within each of the major psychotherapeutic systems that many schools have created new terminologies to highlight their differences (Bongar and Beutler, 1995). For example, Fromm-Reichmann abandoned the term libido in the 1930s in favour of the notion of self as a system comprising ‘the good me’, ‘the bad me’ and ‘the not me’ (Norcross and Goldfried, 2005). Kleinian therapists tend to think in terms of conflicts between the self and internalized objects rather than the id, ego and superego (ibid.). Roger’s ‘actualizing tendency’ has been developed to include the term ‘social mediation’ which cushions the ‘actualizing tendency’ as it introduces a restraining force which helps the person maintain sufficient social contexts (Mearns and Thorne, 2007). Despite the growth in the number of new theories, approaches and terms, the idea of psychotherapy as ‘the talking cure’ has arguably changed much less; listening, reflecting back and questioning techniques remain, for the most part, the same and we are still in the dark about what exactly brings about healing. A fundamental question addressed in this book is: can talk be so powerful that it heals or at least changes a person? In the case of Anna O it was something in the way she talked about her difficulties and something in the way the therapist listened which moved her towards some inner healing process.

Nowadays, at least in the western world, the idea of ‘the talking cure’ is fairly embedded in medicine, psychology, education and the working world as a helpful service. Cushman (1995) argues that psychotherapy today provides a service which reflects the needs of our present-day society, and that throughout history the conclusions drawn concerning mental health requirements are a reflection of society’s structure and the needs of the time. Whether those needs are real needs or fashionable trends is arguable. In any case, the multiplicity of psychotherapeutic models available today which offer a range of ways a therapist can talk to his or her client or patient reflects something of the mental health needs of today’s individuals. The plethora of therapies on offer indicates that no one therapy can claim to have the ‘clavis’ to the absolute truth concerning the nature of human functioning. What we can say, however, is that all psychotherapeutic knowledge deals with knowledge of psychosocial change (Rogers, 1951, 1995; Miller and Rollnick, 2002; De Shazer, 1994; Streeck, 2008).

In today’s working world, there is a growing trend for companies to provide psychological support to employees and their families. This support is largely offered through the services of an external Employee Assistant Programme (EAP). This programme is a managed care system, providing a service designed to help steer employees in the direction of psychological health and well-being, and is discussed in some detail in Chapter 8. It is an acceptable fact today that stress levels are intensifying, burnout is becoming a household term and disorders such as depression and anxiety are on the increase (WHO, 2007). Essentially, EAP providers facilitate clients by offering them psychotherapy and counselling for any distressing psychological issues that may be affecting their ability to perform at work. The goal is to help clients to take control of their own psychological health by providing them with short-term therapy lasting anywhere between four and eight sessions. In order to work in this field EAP therapists and counsellors need to be schooled in therapeutic orientations. The EAP therapist tends to combine the following models of therapy deemed useful for time-limited approaches. Firstly, the humanistic ‘client-centred’ or ‘Rogerian’ model which, focuses on the client’s capacity for growth, choice and creativity, is paramount to this time-limited model. Secondly, the cognitive and/or cognitive- behavioural therapy (CBT) model developed by Aaron Beck, which focuses on maladaptive thinking, assumptions and core beliefs about self, others and the world, can be used to help clients learn to cope with psychological stress and disorders. Thirdly, the solution-focused approach developed by Steve De Shazer and Insoo Berg, which focuses on the client’s inherent strengths, skills and resources, is a necessary prerequisite for any therapist hoping to provide therapy or counselling to EAP clients. All of these therapies stress the importance of the therapeutic alliance.

Furthermore, in recent times, reflective practices, practitioner based research, and continuing professional development programmes (CPD) have become important aspects of professional activity and training within a variety of settings ranging from psychotherapy, nursing and medicine to developmental trainings in the business world. Whilst different professional concerns have diverse roots, it seems that many combine in schemes which promote practice centred professional development. This book, which focuses mainly on psychotherapy, will help mental health practitioners, such as psychotherapists, counsellors, supervisors, doctors, nurses and so on, as well as human resource personnel and managers, to examine their work with the people who seek their services. Such specialists, who work mainly with patients, clients and employees who experience mental health difficulties can learn to appreciate and reflect on talk-in-interaction. The chapters in this book are concerned with examining actual lived practices as opposed to second order accounts of experiences.

The data and subsequent analyses in this book come from a single EAP therapist who came to understand and enhance her practice by using the tools of Conversation Analysis (henceforth CA) to examine the talk occurring between the therapist and the client. The focus is on how this practice is undertaken and examines how the therapist utilizes therapeutic interventions to generate understandings and insights to move the client in the direction of change. It would, however, be beyond the scope of this book to examine in detail all of the interactions occurring so the focus will remain on three basic therapist tools: listening, demonstrating understanding and encouraging long sequences of talk (Chapters 5, 6 and 7). Some extremely insightful processes were gleaned from a microscopic investigation of the data. In addition, I consider some issues which may shape the interactional processes and course of action occurring between therapists and their clients in Chapter 2 and I look at the previous literature done on CA and psychotherapy in Chapter 3. Chapter 4 then considers some other methods used to investigate the practice of psychotherapy and particularly how EAP therapy is at present being evaluated. At the end of each of the chapters I have included a therapists’/practitioners’ corner. Here readers can partake in a guided tour through the devices and tools used by CA analysts when they marry their methods with those used by ‘talking cure’ specialists. There is a twist in the penultimate chapter when the focus turns to the EAP system and to the managers who adopt specific conversational approaches in an attempt to help employees by encouraging them to use the EAP service. A CA analysis of role-plays adopted in training programmes for managers yielded some very interesting findings and the practitioners’ corner at the end of the chapter is designed with managers in mind.

Talk and psychotherapy

Talk is at the nucleus of psychotherapeutic practice. How a psychotherapist talks to a client or patient depends on the theory which influences that practice and the therapist’s belief that their theory will work and they will bring about change. Most research to date on CA and psychotherapy has found that the same interactional practices involved in psychotherapy can be found in any social interaction (Peräkylä et al., 2008; Peräkylä, 2013). The art of listening, asking questions, providing comments, making interpretations and so on, are fundamental skills of verbal interaction which are necessary in all social worlds but what makes them unique in different schools is how and why they are used in particular ways. Psychodynamic therapy holds that if you use talk to engage with a client in a particular way, so that unconscious conflicts are made conscious, psychological changes will occur for that client. Cognitive-behavioural therapists (CBT) use talk to tackle a client’s irrational thoughts and erroneous beliefs to bring about the same effect. CBT therapists also emphasize the importance of the therapeutic relationship. Rogerian therapy considers this relationship to be the essence of the change process (Rogers, 1957, 1995). The person-centred therapist adopts a non-directive approach and uses talk to convey the three core conditions of this therapy- empathy, congruence and unconditional positive regard so that the client can develop a sense of self which is congruent with experience and restore the ‘organismic’ valuing process¹ (Rogers, 1959). In solution-focused therapy, the therapist also adopts the three core conditions of Rogerian therapy but in addition, uses talk to help the client identify solutions that will help remove the barriers which block a client from achieving the life that they would like. Instead of going over past events and focusing on problems, the talk is future focused without today’s problems (Hubble et al., 1999; De Shazer, 1994). While all talk therapies may have the same general goal in mind – to restore the psychological well-being of the client – the moves the therapist makes to achieve their objectives during the course of therapy depend on the therapist’s conceptual model of psychotherapy (Norcross and Prochaska, 1983). An empirical investigation using CA can help ascertain if this is really the case. As the therapeutic relationship is a salient and determining factor in bringing about change, I suggest that this relationship can be investigated using CA because the nature of any relationship will be played out in the talk taking place between the participants.

The idea of change

In short-term work a therapist can hope that after a number of sessions a client will notice that they begin to change, hopefully for the better and that they now cope better with their environment. Such an assumption suggests that a therapist not only has the power to influence change within the sessions but also outside. Dreier (2008) followed up clients after therapy and found that, not surprisingly, there were many other influences in client’s lives, apart from the one-hour weekly sessions, which influenced them to change. If therapists hope that a client changes mainly as a result of insights and understandings gained in the sessions then researchers may require a method of assessing change which would explain how people change within and between sessions. As change is a process which is accomplished over time, it is difficult to evaluate if or how these re-evaluations have brought about change in the client’s life in general, as we do not know how people change after therapy ends (Prochaska, 1999; Dreier, 2008).

Despite these gaps which exist a trained therapist maintains certain assumptions. In the therapy examined here, it is generally assumed that when the client’s level of consciousness has increased with respect to the problem they can then learn to assess how they think about themselves and the problem, express their experiences and feelings about the problem and the solution, and assess how the problem and the solution affects them in their social environment. It is also assumed, that in the sessions these understandings and insights are co-constructed by both parties in sequences of talk which hang together but are guided by the therapist’s approach and theoretical orientation. By using CA to investigate the sequential order one can examine if the therapist is doing what he or she says they are doing (Peräkylä and Vehviläinen, 2003; Peräkyä et al., 2008). However, a therapist does not need to investigate every move made in order to evaluate his or her practice. I am suggesting that a focus on even the smallest of interventions will tell vast tales about how therapy is being conducted. In doing therapy a therapist invites a client to tell his or her story and the therapist is the co-constructivist who helps clients to change that story (Spence, 1984; Meichenbaum, 1995; Maione and Chenail, 1999). The central tenets of all of the therapies in this practice, and stipulated in training manuals, require that the therapist is able to adopt an empathic reflective listening style. This requires that the therapist will create a non-judgemental set of conditions in order to help clients tell their story at their own pace. To do this the therapist needs certain techniques to help the client relate to what happened or is happening in their lives. By investigating basic therapeutic skills, such as listening techniques and empathic interventions during the course of therapy one can quickly determine how this therapist enacts change in the client’s story because the therapeutic relationship is developed by managing the talk. In this book the methods of CA are employed to do these investigations.

The empirical evidence

As already mentioned the investigation deals with the fine details of talk and the focus is on some specific actions which in CA’s terms are called continuers, formulations and extended sequences of turns. Continuers are the mms and ahs and uh huhs and yeahs which a therapist might use to listen. Formulations are typical reflecting back techniques used in therapy when the therapist attempts to clarify what she assumes the client has just said. Sequences are longish snippets of extended talk where the client has the floor and the therapist listens, nudges, steers or even directs the client to keep talking. Using CA, this work seeks to explicate how these actions are performed by the therapist and how the client responds to them: what kind of structures are involved, what way the therapist aligns or misaligns when producing the actions and what one can determine about the therapist’s focus and theoretical orientation by looking at the placement of these actions. Chapter 5 focuses on the therapist who uses continuers to support and pace the client as they tell their story. In Chapter 6 the focus is on the therapist who creates formulations which serve as ‘first pair parts’ and which urge the client to accept or reject them, thus creating ‘second pair parts’. These two parts, therapists’ comments and clients’ responses form some of the basic sequential structures in the dialogue between the therapist and the client in this therapy. However, a sequence can be more than just two pair-parts (Frankel, 1984; ten Have, 1999). In this therapy the two pair-parts or what CA terms the ‘adjacency pair’ is the base structure from which a range of both brief and lengthy sequences can be built (Schegloff, 1968). In Chapter 7 the focus is on how formulations, continuers and questions come together to create extended sequences of talk.

In keeping with the CA paradigm, I examine how the actions of the therapist are examined in relation to the actions of the client and ‘any action of the therapist – be it a question, a statement or something else – expresses an understanding of the patient’s experience, and an understanding of how that experience can and possibly should be related to’ (Peräkylä et al., 2008, 2013). The ideas presented should help practitioners to move their focus from therapeutic techniques and theoretical understandings of what one thinks should be happening, because of a particular intervention, to what is really happening. By explicating the details of how the therapist designs and uses these actions – and how they can come together in extended sequences – one can determine how a therapist informed by specific theories relates to the client to help him or her change their ways of coping with the problems which life throws at them.

CA can perform this task as it can be used to enter into dialogue with the theories and codes of conduct found in the manuals and texts which inform these practices (Peräkylä and Vehviläinen, 2003). By entering into dialogue with what Vehviläinen and Peräkylä (ibid.), following Schutz (1967) conceptualize as ‘professional stocks of conversational knowledge’ or SIKs, CA can correct or extend claims made by the therapists that they are bringing about change in their clients because they are doing therapy in a particular way, for example using interventions in a particular way. CA can therefore be used to help therapists reflect on their actions. Ideally therapists, informed by an empathic approach, will make use of their training and experience to talk about sensitive issues in an empathic and non-judgemental way and will not consciously try to get the client to solve his or her problem in the way the therapist sees fit. By applying the skills learnt in training, the therapist can help the client to make decisions about change and to assume responsibility for that change (Miller and Rollnick, 2002). However, this is the ideal and not every therapist applies these skills without imposing ‘their own stuff’ in the form of evaluations, judgments and defences. Sometimes therapists can be affected and constrained by pressures coming from the EAP organizations, whose company policies can determine the length of the therapy and what would be expected to be achieved in a certain space of time – thus putting pressure on the therapists. As CA...

Table of contents

• Cover
• Title
• 1 Introduction
• 2 Interaction Issues in Short-Term Psychotherapy
• 3 Conversation Analysis and Psychotherapy
• 4 A Note on Methodology
• 5 On Active Listening in Short-Term Psychotherapy
• 6 On the Use of Formulations in Short-Term Psychotherapy
• 7 Sequencing in Short-Term Psychotherapy
• 8 Employee Assistance Programmes: A Management Tool
• 9 Conclusions and Implications
• Notes
• References
• Index