Helping Clients Tell Their Stories in the Therapeutic Dialogue
By:Jeffrey W. Dieters MA, RP
Clients look to therapists for guidance with problem issues they consider beyond self-management. The therapeutic dialogue represents a critical and decisive engagement that sets the stage for presenting narratives, defining issues, formulating goal-oriented outcomes and creating strategies that inspire motivated action. To underestimate the value, the stakes, or the potential outcomes of the therapeutic dialogue would be tantamount to culpable disregard – or perhaps even gross malfeasance– especially when clients report sustained problematic symptoms or terminate therapy prematurely. Therapists can enhance the therapeutic dialogue and improve client satisfaction by using probes, being aware of distorted listening, challenging client presentations, discerning reluctance and resistance behaviour, and developing empathy.
The Benefits and Risks of Using Probes
The intended purpose of probing is to gather any helpful information that will optimise goal formulation and increase the potential for successful outcomes. By using probes therapists can assist clients to “identify and explore opportunities…clear up blind spots…translate dreams into realistic goals (Egan & Schroeder, 2009, p. 150) and exhibit genuine interest in understanding every possible nuance of their multidimensional story. Probing questions create the opportunity to develop a more complete picture of the client’s story from which to formulate a therapeutic plan. Without pertinent information an action plan is incomplete. For example, knowing a client’s history of unsuccessful treatment completions may help in the selection of alternative treatment options. Other potential benefits include helping clients to fully participate, to be clear and concrete in presenting the problem situation, to disclose and describe perspectives and intentions, to unearth all relevant information, to consider other viewpoints, to navigate and stay focused on a change-oriented process, and to encourage the skill of challenging self while recognizing the benefit of being challenged (Egan & Schroeder, 2009).
A risk factor relative to probing may include a client feeling overwhelmed by a barrage of multiple questions – especially those that are considered as not having a direct bearing on the presenting problem. In a correctional setting (where I provide therapy) inmates can feel scrutinized, observed and suspicioned throughout the incarceration process, and may therefore be reluctant to disclose information deemed sensitive or personally intrusive. Thus it is important in a therapeutic session that exploration not be unreasonably invasive or increase feelings of vulnerability. Another risk may involve possible misinterpretations of verbal or non-verbal probing. A probe can relay the wrong message from what was intended. For example, I once asked a client why he was at the location where he was arrested. He retorted with a defensive and challenging tone, asking, “Are you suggesting that I knew what was going down? I didn’t know he planned to kill them…Nobody fuckin’ believes me”. My question had more to do with my curiosity than what the client wanted from the helping dialogue. The tone of our discussion changed as a result. A probe can disrupt both the client-centred process and the therapeutic relationship if caution is not exercised.
A technique for probing may take the form of a statement that asks the client to provide clarification or an enhanced description. I may respond to a client’s story by stating, “I’m trying to follow you, but I’m not sure I understand what you mean by…” Another method involves making a request for more information (e.g., “Can you describe for me what you mean when you say you went into a rage?”). Questions are the most common form of probing for information from clients. Open questions (e.g., “How afraid were you?”) are preferable to closed questions (e.g., “Were you afraid?”) as they elicit more client-originated information. Also, using a single word or phrase that communicates a need for further explanation sends the signal to the client that he or she is being heard and that more clarification is desired. Accentuating the client’s choice of words helps to stay focused on the issue at hand.
Probes are an effective way of guiding a client through the storytelling process. When applied appropriately, probes express interest, empathy and attentiveness – which are often appreciated as a rare commodity in a correctional setting.
A therapist’s primary role is to listen intently to client presentations. When listening involves preconceptions, or incorrect interpretations, a therapist may be prone to distorted listening. Egan and Schroeder (2009) have highlighted six forms of distorted listening. They include filtered listening, evaluative listening, stereotype-based listening, fact- centred rather than person-centred listening, sympathetic listening and interrupting. Two forms of distorted listening I have experienced and am challenged by in my context of helping include evaluative listening and sympathetic listening.
In a correctional setting there is a tendency to regard clients according to the particulars of their offence history and assessed classification (e.g., maximum security). Many clients are well known in our facility as “recidivists” (i.e., repeat offenders) and are often treated as incorrigible. As a frontline staff member I am privy to a client’s criminal/legal reason for being incarcerated. But as a chaplain/therapist I try to maintain an awareness that complex personal factors are also relevant and remain for the most part unknown – until opportunities are created to unearth this material. By taking a holistic approach (i.e., considering any and all biopsychosocialspiritual factors), I am able to reduce the tendency to assess clients based solely on behavioural reports. In fact, unless one is postured to listen to clients beyond the presenting information, distorted listening is likely to occur. As Egan and Schroeder (2009) point out, unless clients are first understood, then helped, the default of an evaluative listening approach can result in “advice giving”, which may “put clients off” (p. 118).
It can sometimes be challenging to resist the urge to just tell a client (from a position of expertise) how to navigate his predicament before understanding the complete story. On this point my strategy to prevent premature helping involves taking the time in the first session to listen and formulate a clear understanding of the client’s request before succumbing to the pressures of the “I need it now” sense of urgency that often accompanies inmate requests for help. Another strategy used to counter an evaluative-listening-tendency involves mentally separating a person’s behaviour from other aspects of the person. I cannot help but disapprove of (and sometimes be repulsed by) an offender’s criminal acts; but when I meet with a particular offender I try to maintain a non-biased and professional demeanour that focuses on the nature of the request, and the reasonableness of providing services. This strategy has been particularly difficult for me (e.g., In two separate cases one of my clients murdered another, which created a multi-level personal and professional conflict).
Another form of distorted listening that can affect the therapeutic process is sympathetic listening. It is important to differentiate between sympathy and empathy when counselling clients. Empathy – the ability to discern and even feel or sense a client’s emotional experience – is an asset in formulating a therapeutic relationship; sympathy can compromise the role of the helper and, by way of transference and countertransference, “reinforce self-pity” (Egan & Schroeder, 2009, p.119).
In my dual role as chaplain and therapist I am expected by many to be compassionate and caring on a personal level, while at the same time providing a professional service. I must admit, the line between empathy and sympathy is a fuzzy one for me. Sometimes I have a tendency to take sides as an “accomplice” (p. 119) in the helping relationship. Other times I am caught in transference and countertransference and may disclose personal experiences in the counselling dialogue. Most often I am aware of the limits of this vulnerable interaction. But the tendency to succumb to sympathetic listening is prevalent by nature.
So, strategies that minimise the potential for this type of distorted listening include two approaches (for me). First, if I am engaged in a dialogue that begins with an emotional storytelling, I listen intently for key factors (i.e., problems/complaints) that will form the basis of our collaborative problem/solution-management focus, respond when appropriate to the client’s presentation by acknowledging the emotion that the problem is connected to, and then discern what type of support the client is requesting (e.g., pastoral presence, advocacy, therapeutic intervention). Secondly, I try to communicate to the client what resources and options are available to address the identified issue. An emotional presentation may require tissues, more time in a quiet space outside the unit, a private phone call to family, or a scheduled follow-up session – rather than a sympathetic hug.
Challenging clients means endeavouring to “do some reality testing and invest what they learn from this in their futures” (Egan and Schroeder, 2009, p. 170), and to encourage them to challenge themselves by exploring available ways and means of achieving desired outcomes. As therapists we can be instrumental in providing other viewpoints, exposing cognitive distortions, enhancing self-assessment strategies and even being the “devil’s advocate” in constructive or deconstructive ways.
Five challenge targets include self-defeating mind-sets (e.g., affirmed or imposed negative stereotypes from others), self-limiting internal behaviour (e.g., believing treatment will be ineffective), self-defeating expressions of feelings and emotions (e.g., hopeless resignation that bail will not be granted), dysfunctional external behaviour (e.g., refusing to converse with correctional officers in accordance with the inmate code) and discrepancies in thinking and acting (e.g., “I’m incarcerated for trafficking narcotics to support my family”)(Egan & Schroeder, 2009).
Challenging adult male clients in a correctional setting involves potential risks (e.g., aggressive behavioural responses, misinterpretations, emotional response that may incur hostile behaviour from other inmates if viewed as vulnerable). It is prudent therefore to ensure directed challenges are delivered at an appropriate stage in the helping dialogue and in a manner that is compatible with an established therapeutic relationship.
It is sometimes difficult for me to challenge clients who are being disruptive in a group counselling session. Given the inmate subculture, such a challenge would pose two possible responses. They either take responsibility for the challenged behaviour and modify it to satisfy the challenger; or they view the challenge as a threatening confrontation that requires a hostile retort to ‘save face’ in the presence of other inmates in order to avoid the appearance of being perceived as weak. I have experienced both scenarios.
I have learned to prevent most potential risks related to challenging by understanding the social culture within a correctional setting and by enhancing my skills training. To reduce potential difficulties with challenging, I look for areas that challenging would represent a benefit to clients and would be most effective in addressing barriers to optimal functioning (e.g., improving the therapeutic relationship, better social integration among peers).
I once completed a “conflict style” inventory questionnaire that indicated avoidance as being my primary approach when faced with potential stress related to interpersonal conflict. This awareness has enabled me to consider and reflect on situations where challenging clients may represent my need to maintain conflict-free functioning rather than addressing the client’s need to be challenged. Another technique to reduce challenging difficulties involves making sure group rules and information about treatment methods are communicated, which minimises potential misunderstandings and clarifies expectations, limits and procedures.
Managing Reluctance and Resistance
As a supportive helper of those who are experiencing personal problems I find that most are collaborative and engaging in the solution-seeking process. However, some clients do exhibit a lack of confidence or even an almost antagonistic posture in the initial stages of the helping dialogue, which can affect not only the helping process but also the development of a therapeutic relationship. I must admit, as a therapist, I may be more committed (unconsciously) to clients who demonstrate positive interpersonal cooperation than those who don’t. In the correctional context of my work it is common to experience disgruntled clients who tend to draw negative rather than supportive attention. As a therapist in this cultural milieu I must be mindful not to withhold support services from those who exhibit what is interpreted as reluctance or resistance behaviour. This can be a challenge when others who engender treatment-ready enthusiasm are waiting in line.
A client who exhibits reluctance in the helping process may be wary or cautious for many reasons. Egan and Schroeder (2009) suggest several possible reasons for client reluctance or resistance including: fear of intensity, lack of trust, fear of disorganization, shame, stigma, the cost of change, loss of hope and values conflict (pp. 225-227). Any one of these can represent a valid explanation for a client who may not yet have the capacity to engage in a formal change process without having conscious or unconscious reservations. Until a client’s reluctance to engage in the helping process is understood helpers may be prone to incorrectly interpret such behaviour as disinterest, resistance, or some other form of uncooperativeness. I often encounter individuals who are reluctant to disclose how personal struggles are affecting them. In the culture of corrections emotional expressions are famously withheld (except for anger); thus a first impression of a reluctant client may not necessarily reflect a valid assessment of motivation when based on presentation alone. It is important therefore, that reluctance behaviour not be viewed as a barrier to treatment, but rather an indicator that further assessment and exploration may be required in the treatment planning process.
Resistance, as compared with reluctance, represents a more defensive posture expressed as “the push-back from clients when they feel they are being coerced” (Egan & Schroeder, 2009, p. 224). A client may have misgivings (i.e., a passive reluctance) about engaging in a helping process (based on internal or external cues), or respond uncooperatively (i.e., active resistance) to what may be perceived as a threat originating from the helper or the intervention process. If resistance is not managed in a way that clarifies the client’s presentation and affirms the client’s choices, the potential for intensified resistance behaviour or premature termination increases. Clients who are mandated or supervised within a support system (e.g., incarcerated, on probation) may exhibit behaviours indicative of resistance (e.g., avoidance, silence, non-disclosure, or even hostility). Keeping in mind that resistance behaviour may represent personal defence mechanisms that “serve to maintain our self-esteem and keep our sense of self intact” (Egan & Schroeder, 2009, p. 231), a therapist would be wise to examine his or her own responses to determine whether they reflect an affirmative or dismissive tone. Responses to reluctance and resistance behaviour would be more productive by recognizing that these behaviours exist within the helper and can be viewed as relatively normal, which makes it easier to accept them, and work with them. Therapist tasks include: understanding low client motivation factors (i.e., avoidance), enhancing self-awareness of helper competence and interpersonal communication styles, having realistic expectations regarding client participation and outcomes, developing a client-empowering therapeutic relationship, exploring for incentives that reduce resistance, expanding helping resources (e.g., family members), and when possible “employ the client as a helper” (Egan & Schroeder, 2009, pp. 234-5).
Applying these and other strategies in the therapeutic enterprise will help address the prevailing challenges inherent in working with clients who perceive treatment as an invasive experience. In the correctional environment I meet clients who are either motivated to seek treatment and/or supportive coping resources, or resist intervention for reasons that involve unknown factors (e.g., distrust, precontemplative of change, cultural codes of conduct). Personally, I operate on the theory that even perceived unmotivated clients are thoughtfully engaged in managing their problematic issues (successfully or unsuccessfully), and are generally aware of treatment options – whether they are ready to access them or not.
Empathy has been highlighted in the helping profession as one of the pivotal helper tools that are needed in building a therapeutic relationship with clients. Carl Rogers (1975) in his Person-Centred Therapy approach identified empathic understanding of the client’s internal frame of reference as one of the necessary attitudes that a helper must possess and exhibit in order to gain access to a client’s private world.
Empathy has been defined in many ways. Egan and Schroeder (2009) describe it as a personality trait that inclines one to sense the internal experience of others – more than those who are not so inclined; a situation specific skill that seeks to understand another’s experience in order to provide a service; a process with stages that interchangeably communicates the felt experience of the other. Or, empathy can be simply and subjectively defined as one’s capacity to care. In this sense, “having” empathy does not necessarily presuppose active engagement (passive engagement?), but rather describes the attentive posture of one who expresses interest and concern. In my work with clients and staff as a correctional chaplain and therapist empathy is presumably equated with compassion and benevolence (i.e., unconditional positive regard) – as though my vocation was evidence that these qualities were present. Arguably, I have known clergy and therapists that did not particularly exhibit these presentations.
In the helping process empathy finds its expression in being intentional about developing a contextual understanding of a client’s viewpoint and communicating it when appropriate – especially when there is incongruence between the expressed viewpoint and reality (Egan & Schroeder, 2009). Personally, I try to create a space and demeanour wherein the client feels he or she has my undivided attention, where confidential disclosure is possible, and where catharsis may be safely expressed. Only then can I collaborate with the client to confirm and affirm the lived experience at issue before moving to solution-talk.
While being empathic may be one of my natural (i.e., personality traits?) propensities, I sometimes struggle with clients who are manipulative or have mental health issues and make it difficult for me to formulate an interpersonal connection. In a correctional context there are many desperate individuals who seek my attention, so I have limited tolerance (i.e., attentive capacity) for individuals who behave poorly (e.g., disrespect, making invalid claims, requesting intervention from several professionals at once) to get immediate and/or increased attention. Given my role, I may not present as other staff members do (un-empathetic?), but I do discriminate in my selection of those I choose to help, and am self-protective of my capacity to be caring (i.e., empathic). Compassion fatigue (i.e., burnout) is a real danger for the caregiver. In fact, I would argue that empathy (creating a psychological-emotional symbiotic connection) introduces potential risks for the caregiver (e.g., vicarious PTSD-like symptoms).
Strategies for developing a healthy form of empathy in my practice include engaging in ongoing research in the helping field (e.g., courses, workshops, reading), increasing my awareness of personal strengths, weaknesses and skills as a care provider, intentionally directing my focus to areas that are compatible with my competence, personality and scope, and limiting my empathy to avoid compassion fatigue. Caring too much or unwisely can be careless. Helping clients tell their stories in the therapeutic dialogue requires both an artisan and a skilled clinician.
Egan, G. & Schroeder, W. (2009). The skilled helper: A problem-management and opportunity-development approach to helping. Toronto, Canada: Nelson Education Ltd.