You can always be misunderstood

There are two aims in any conversation: unambiguous expression of your own position and complete comprehension of the other person’s views. We should always remember that neither of these aims is a realistic goal.

A client told me of an ante-natal appointment at which her midwife said “So, your first child was deformed and your second child was killed: let’s hope it’s third time lucky, shall we?”

While it is difficult to imagine anyone not being offended by such insensitivity, it is equally hard to believe that the midwife was being intentionally cruel. If she thought at all about her comment, she may have imagined she was being warm & humorous: rapport-building.

While serving as a Member of the Finnish Parliament, communications researcher Osmo Wiio proposed his “laws of comunication”, including:

  • If communication can fail, it will
  • If communication cannot fail, it still most usually fails
  • If communication seems to succeed in the intended way, there’s a misunderstanding
  • If you are content with your message, communication certainly fails!

Clients are often mystified by someone’s negative reaction to what seemed, to them, to be a reasonable statement or request. In discussing such situations, we usually conclude that it is possible to misunderstand even the most clearly worded request and to be offended by even the most innocuous statement: what the speaker says may have little to do with what the listener hears.

Clients who are anxious or depressed may be less able to attend to either expression or comprehension with the same care & attention as their therapist. Therapists’ comments & questions, however clearly articulated, may still be misinterpreted because the client is not paying full attention or has information of which the therapist is unaware (but which the client may think the therapist knows).

Misunderstandings & unfortunate comments can be worked through given time and effort, but neither of these will be forthcoming from a therapist who thinks that their own communication is unambiguous.

Improve rapport by allowing silences

Clients’ perceptions of rapport may be enhanced by silences. Therapists who are uncomfortable with silence should remind themselves that their client’s interpretation of the silence may be much more positive.

A client once asked me not to delay speaking once he finished a comment. He explained that his school report was always sent home in a sealed envelope. He would be forced to stand in silence while his father read the letter, not knowing whether the report was favourable or how his father would react. Three decades later, he experienced the same anxiety during silences in therapy. Agreeing that he was no longer a school child and that a considered response from me was likely to be better than a hasty response helped him overcome his anxiety about my silence.

Therapists may also be uncomfortable with silence in therapy. Time or results conscious therapists may feel that silence is not the best use of the limited time available in a session and may seek to pack as much into the discussion as possible. Other therapists may wonder whether silence means that their question or comment has confused, distressed or even offended the client. Rather than endure the silence, they may rephrase their question or seek to clarify or qualify their comment. Further silence may lead to further rephrasing.

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Closed questions can be supportive for clients

Judicious use of open & closed questions can empower clients. Restricting the range of responses when some are inappropriate or unavailable demands more of the therapist, but can be more supportive for the client.

One benefit of speaking slowly is that you get to think about how you frame your questions. The considered use of open & closed questions is a therapeutic skill often mentioned in workshops and textbooks but neglected in practice.

Open questions can be used for initial information gathering (“Tell me about your childhood”) and closed questions used to clarify the information given (“Were you abused as a child?”).

Closed questions restrict choice of response. They allow only a handful of responses (eg: yes or no) without stepping outwith the frame of the question (“I don’t feel comfortable talking about that”). Many clients are insufficiently assertive to sidestep the question and may feel pressured into premature disclosure of information (or lying) by closed questions.

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Slow speech makes for clear communication

Speaking more slowly can improve communication between therapist and client. Slow speech is more comprehensible and more considered.

Anxiety is characterised by rapid speech. Therapists, especially trainees, may be anxious in sessions, but may also feel the need to speak more quickly in order to pack more into the time available. This can backfire by making the therapist seem anxious.

Following rapid speech demands greater attention. When listening, we are attempting to make sense of what is being said. The more time we have to consider what is being said, the more likely we are to understand what we are hearing.

Clients are by definition functioning less than optimally. Anxiety, depression, pain, fatigue and medication effects can impair concentration and therefore affect clients’ ability to follow and make sense of what we are saying.

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Writing when you speak preserves eye contact

Writing only when you are speaking maintains normal eye contact. This serves to normalise the interaction, reassures the client that they have your attention and that you are writing what they are saying.

Writing while the other person is speaking reverses the normal pattern of eye contact.

Anyone who has had a medical appointment will know the unease associated with describing your symptoms to the top of your doctor’s head. They write feverishly while you speak, only meeting your gaze to ask a question, then dive back into their notes again as you begin your answer. All the while you’re asking yourself: what is it that they’re writing about me?

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Disclosure is promoted by permission not to speak

Giving clients permission not to speak encourages disclosure. Explicitly granting the freedom to subvert our power frees the client to tell us what they need.

The first time is to check out the therapist, the second is to tell you the real problem.

I was given this advice in training and for years it seemed to be true. Now, in my practice at least, it is the exception rather than the rule.

The balance of power in therapy lies with the therapist. We decide when, where and for how long is each appointment. We set the boundaries and grant exceptions. The client must work within our framework.

Clients can exercise control by withholding information or themselves. Failure to attend is the ultimate means of regaining control of therapy. More subtly, the client can, without overtly challenging the therapist, keep back important facts for as long as they choose.

Full disclosure can occur in the first appointment if the client has permission to withhold. I tell clients “if there are any questions you don’t feel comfortable answering, that’s OK”. It is now rare for clients to surprise me in the second appointment (unless I forget my line).

The underlying process may be that, having been given permission to withhold, the client can now exercise control by disobeying you…and telling all. This appears manipulative but this accusation would be genuine only if the permission to withhold were false, given only to manoeuvre the client rather than arising from a genuine respect for their privacy.

Eye contact tells you when to speak

Steady eye contact from a client is your prompt to speak. Attending to eye contact helps us to minimise interruptions of the client’s train of thought and to be more comfortable with silences.

In 1:1 conversation we spend 50% of our time looking at the other person. It is important to remember that this is an average across two distinct roles: speaker and listener.

When listening, we look for 50–90% of the time. We can see expressions and gestures, the non-verbal modulators of the spoken word. More importantly, we can see if the other person shows signs of finishing, so that we can have our turn.

When speaking, we look from 10–50% of the time. We need to know that the other person is listening, but we can reassure ourselves of this with a quick glance. When we have the floor, it is more useful to look away from the other person, minimising distractions from our train of thought.

It is difficult to be sure when someone has finished speaking. A pause may be for reflection or may be the signal that you have the floor. In ordinary conversation between equals, interruptions are inconsequential, easily remedied in the to & fro of the chat.

Interruption by a therapist can discourage a disclosure. A client who has stopped speaking may be awaiting a response or marshalling their thoughts. Speaking just as the client is about to can distract at best; at worst, it can be taken to mean that the forthcoming disclosure was unwelcome or irrelevant.

You will know it is your turn to speak when they look steadily at you. A quick glance need only be to check that you are still listening. A steady gaze indicates that a reply is now expected.