Therapists’ questions to clients about what might be helpful can be supportive without being directive: a conversation analysis

ABSTRACT

Shared decision-making about therapeutic methods has been proposed as a way of conceptualising, and assisting, collaboration in the therapeutic alliance. However, little is known about how psychotherapists actually create concrete, moment-by-moment opportunities for clients to share their ideas about what might be therapeutically helpful. We used conversation analysis to examine psychotherapists’ questions about what might be helpful in audio-recordings of early sessions of a collaborative-integrative therapy. We examined forty-two sessions involving seven dyads and identified 28 cases of questions either inviting clients’ ideas about helpful in-therapy methods or strategies outside the therapy room. Psychotherapists could invite clients’ ideas by using simple questions, however clients could find such questions problematic. Alternatively, psychotherapists could add scaffolding: offering support to the client in terms of how they might respond. However, this could erode clients’ autonomy to respond with their own ideas. We identified a conversational practice, de-specifying, which overcomes this dilemma: asking questions and providing scaffolding whilst also lessening the pressure on the client to go along with that scaffolding. A therapeutic style which includes scaffolding and de-specifying practices creates an opportunity for the client to contribute where clients are empathically supported, but not directed, in responding.

KEYWORDS:

• Integrative psychotherapy
• preferences
• collaboration
• conversation analysis
• shared decision-making

Acknowledgements

We’re very grateful to the clients and therapists who consented for their sessions to be recorded for research purposes. We’ve benefitted from comments on previous versions of this work which we gratefully acknowledge. In particular, we would like to thanks anonymous reviewers and the editor of the journal.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was funded through a doctoral research bursary funding from the Psychology Department at the University of Roehampton to the lead author.

Notes on contributors

Sarah Cantwell

Sarah Cantwell is an accredited Counsellor and Cognitive Behavioural Therapist, working full-time in a primary care psychological service in the NHS. She completed her PhD at the University of Roehampton where she used Conversation Analysis to examine how concepts like collaboration relate to the micro-level of interaction in psychotherapy.

John P. Rae

John P. Rae is Reader in Psychology, University of Roehampton, UK. His research focuses on talk and body movement in social interaction in both informal and service-related settings, including psychotherapy. He is interested in human diversity, particularly in interactions involving participants with autism spectrum disorder. He recently co-edited Atypical interaction: The impact of communicative impairments within everyday interaction (with Ray Wilkinson and Gitte Rasmussen, Palgrave Macmillan, 2020).

Jacqueline Hayes

Jacqueline Hayes is a researcher and practicing psychotherapist/counsellor. She is Senior Lecturer in Counselling Psychology at the University of Roehampton, London, and has worked previously at the University of Manchester and the Anna Freud Centre, UCL. She specialises in relational approaches to voice-hearing and analysis of psychotherapeutic interaction.

Joël Vos

Joël Vos PhD MSc MA CPsychol FHEA is a psychologist, philosopher, researcher, lecturer, and existential therapist. He works as Senior Researcher and Senior Lecturer at the Metanoia Institute in London, United Kingdom. His research focuses on topics around meaning in life, social justice, and the effectiveness of humanistic and existential therapies. He chairs the IMEC International Meaning Events & Community which organises annual conferences, workshops, training, and cultural events (meaning.org.uk). He has over 100 publications, including the books Meaning in Life: an evidence-based handbook for practitioners (MacMillan, 2017), Mental health in crisis (Sage, 2019), The economics of meaning in life (University Professors Press, 2020), and The psychology of COVID-19 (Sage, 2020). Read more on joelvos.com Email: [email protected]

Mick Cooper

Mick Cooper is Professor of Counselling Psychology at the University of Roehampton, where he is Director of the Cluster for Research in Social and Psychological Transformation (CREST). Mick is a chartered psychologist and author and editor of a range of texts on person-centred, existential, and relational approaches to therapy. His latest book, co-authored with John Norcross, is Personalizing psychotherapy: Assessing and accommodating client preferences (2021, APA). Mick is the father of four children and lives in Brighton on the south coast of England.