Therapists are programmed to listen, and helping clients to feel heard is at the heart of what we do. There are times, however, when something seems to go wrong with this process, and although the therapist has applied the most careful attentiveness, validation and change suggestions the client wants to recount the same information over and over again. Therapists report that too much going over the same ground feels wrong, they can sense it is not helping and they feel stuck in a loop. As a behaviourist I am going to ask, “What is reinforcing this client behaviour?”

There could be any number of controlling variables.  The first possibility is that something pleasant happens inside the client when they tell their story. The most common internal reinforcer is hopefulness. So at the point that the client retells their story they experience a surge in hope that on this occasion a desired outcome will occur – perhaps they will feel relief or the therapist will come up with a different solution. This is the same mechanism that gets people buying lottery tickets even when they never win. To the client, recounting the story means, “I have not given up, I am still in with a chance of a different resolution to this issue.”

Another internal positive reinforcer is a sense of congruence. The active ingredient here is not the therapist hearing the story, but the client connecting with their own accurate description. Their inner validation; “That’s right! That is EXACTLY how it is!” can be very rewarding. Watch to see if the client is scanning your face for clues to your response, or if they appear to be watching a film unfold in their mind’s eye, quite separate from you. If it is the second they are probably after an internal sensation rather than anything you can say or do.

Retelling is more likely if the story is emotionally evocative and the client has few other experiences in which to employ their full emotional range. When you think that the entire multi-billion pound entertainment industry is built on dragging us poor punters through every available emotion; terror, horror, despair, relief, joy, excitement then you can see just how important it is to experience those emotions in everyday life. If the client’s only emotional outlet is in the therapy room, then “Houston, we have a problem…” If you are the client’s sixth therapist, suspect that this variable might be in the driving seat.

Self-justification can be very powerful. If someone has hurt me and here I am contacting that pain then it proves I was hurt. If I am the victim of an injustice and here I am in connection with that grievance it is clear evidence that the injustice took place. It is reassuring to any of us when our experience fits the facts. For some, to let go of retelling can feel like letting the person who hurt them off the hook. This is the saddest of them all, where potential years of happiness are sacrificed on the altar of bearing witness to injustice, and yet for many the crime against them is indeed so great that it takes a superhuman effort to reclaim their rightful pleasure from life.

The response from the therapist can also reinforce the behaviour. An understanding look, a reassuring nod, the giving of time to listen. If the very first time the client told their story they experienced a huge surge in positive emotion from these things why would they not want more? It can be like being let out of prison after a long term, and the client seeks to replicate that feeling. This is the same mechanism that maintains substance misuse, where the person ingests more of the substance hoping to replicate the initial high – but takes it beyond that point, to where only lows are waiting.

Negative reinforcers are the removal of unpleasant consequences. So if the client can get the therapist onto a familiar and well-worn track they may be keeping them away from other more painful topics. In some way the client is taking control of the session.

Equally if the client has underlying misgivings about their own behaviour during the critical incident they may wish to ‘anchor in’ their version of it, to steer themselves (or the therapist) away from the part that causes them most doubt. For example it may be that they are defending against a feeling of guilt. Although that guilt could be justified or entirely inappropriate, it is the lurking presence of unacknowledged doubt that condemns them to a perpetual cycle of restatement.

Finally there is the fear of forgetting. The protective injunction to avoid traumatic events is so strong that the client is afraid of unhooking from the incident. They worry that such carelessness might leave them victim to the same thing happening again. Alternatively if the incidents they recall evoke pleasant memories then they fear that these will become inaccessible if not regularly shared.

So what can a therapist do having assessed the drivers for the behaviour? My top tip is to start by honouring the story told. In 80% of cases one simple strategy will result in change – the therapist starts a session by saying – before the client has even begun to speak – “I have been thinking about you, and about the incident we have been discussing, and remembering that you….”(here the therapist tells their story back to them in their own words.)  Don’t paraphrase, use exactly the words they use. Timing is crucial here – it simply does not work if you wait until the client has begun the recounting. You must get in before the incident is mentioned or referred to, because it is your unprompted remembering that is so effective in reassuring the person that they have been heard.

If this doesn’t stop the behaviour then a second line strategy is to type out the story in a letter to the client and hand it over in session, “I believe that this is a very significant event and it is important we keep the details, and add to them if we feel we are missing something.” Then keep a copy of the document with you so if the client begins retelling you can get it out and see if anything needs adding in. Seeing the therapist do this can act as a reminder that the story is not lost, but also offers a chance for the client to expand on any missing links.

If neither of these strategies reduce the behaviour I would suspect it is to do with a dearth of other emotionally evocative events outside of your sessions. I have used a diary-card for this problem, asking clients to tot up daily the minutes of thinking-time devoted to their repeatedly described incident or situation, and then in a different column to track ‘new life thinking.’ This is any time devoted to planning or engaging in activity to build or refresh their daily emotional experiences. I am quite demanding that one figure should be reducing while the other needs increasing.

If this doesn’t work then track their urge to tell the story to you. As soon as the re-telling begins, say, “I wonder what was going on for you right then when you had the urge to tell me this?” Try to pinpoint the thought or emotion that acted as a trigger. Then you might be able to work out out how the recounting of these familiar details either reduces or enhances the thought or emotion.

If absolutely all else fails then hand the problem over to the client in a radically genuine way; “I know that telling me about this again seems to be important, but I am worried that if we keep our focus here we are not going to move forward in therapy. Can you help me to make sure that we don’t just go over old ground?”

Knowing the function of a behaviour always leads to more insight into what the therapist could do to help alleviate it.

The emotion of shame is one of the social emotions designed to keep us as part of a social group, as during evolution the protection of others was a big factor in our survival. Shame occurs when you have committed an act that you predict would be against the norms or values of your group, to such an extent that if the group knew about it there is a risk that you would be ejected from the tribe. Unlike guilt which prompts us to try to repair the damage, the emotion of shame has an action urge of hiding or concealing one’s crime.

This is an excellent protective instinct. If you have done something hideous and you don’t think you will escape the wrath of your peers, the behaviour of keeping a low profile could allow any tribal heat around your transgression to die down. Hopefully everyone will forget about the incident and you will be assimilated back into the social structure when you eventually surface.

It makes sense that an emotion that served such an important life-or-death function would have an accompanying sensation that feels pretty horrid. Shame is particularly painful and so it should be – so that there was no risk of you wandering out nonchalantly into a crowd that is baying for your blood.

The components of the emotion are body heat (burning with shame) an urge to hide from view which leads to head hanging and shrinking back, a subservience to others and self-accusatory thoughts. Unlike sadness where muscles are flaccid, in shame it is possible to note a certain amount of flight-tension, i.e. the muscles retain a readiness to run or push others away. Think of trying to comfort someone who is very ashamed, they may push you off in a way that sad people are less inclined to do.

So we can distinguish shame from related emotions like guilt or sadness. Occasionally shame can elicit defiance as an internal defence, so it can mimic anger, but the tell-tale signs are in the direction of motion – the angry person is more likely to approach others, the defiant person will stand still.

Professor Paul Salkovskis has suggested to ask clients, “What kind of people feel shame?” They have often failed to register that it is an emotion felt by people who have a conscience. Psychopaths and hardened criminals rarely exhibit shame, although there is also an argument that they have just become more practiced at defending against it.

The compassionate mind theory of Professor Paul Gilbert suggests that many clients have not developed the part of their brain that can show compassion to themselves, and need to be helped to do so. People with this problem may believe that the pain of their shame is well-deserved.

In taking a behavioural approach to reducing shame we first want to be mindful. In the presence of a shame-inducing trigger clients can be only too quick to lump together anything and everything that they have ever felt ashamed of. So when treating a current episode of shame it is vital to ascertain what exactly set it off. Questions like, “what is the latest thing that made you feel ashamed?” are helpful. You simply cannot treat shame in a global way, you have to teach the client to work incident by incident.

Try to establish if their current episode of shame is one of the following

1. I have committed an act where most people would reject or judge me for it if they knew (justified shame)
2. I have committed an act that if someone else did it wouldn’t seem shameful, but I am sensitive about it (unjustified shame)
3. I perceive that others are judging me for a failure to do or achieve something in comparison with them (potentially justified shame the client needs to assess whether being part of this group is important)
4. I have done something where a degree of guilt is justified, but I just react with such intensity it turns into shame. (shame that is unjustified by degree)
5. I was an innocent party to or victim of another’s actions but feel shame about the event (Unjustified shame by association)

Clients need to learn these types of shame, as stepping back from the incident in question to classify it will usually take a little of the heat out of it.

Some therapists hold that shame is never warranted, but I disagree, having consulted to teams that deal with patients who have committed very serious crimes such as murder. If such clients are ever released and hear taunts or threats in public the urge to hide could save their life. This is especially true if they have been rehabilitated with a fresh identity, being in danger of revenge attacks. It is also realistic for clients who have past self-harm or drug habits to assume that some groups might reject them and it is wise for them to be discerning if the social stakes are high.

When treating shame the therapist MUST ascertain the nugget of truth in the patient’s position. Saying to clients, “you have absolutely no reason to feel ashamed,” is often invalidating – because for some reason they do feel it. So the therapist is looking to find one sentence, just one, that sums up succinctly the reason that the client feels shame, but – and here is the art – it is tempered with more reasonable language. So the client who has had her child taken into care because of her self-harming might be taught to say, “I would prefer that I had not self-harmed because of the consequence of having my child removed, it does not fit my values to live separately from my child” the therapist will know that the sentence is correct because the client says, “yes, that is exactly the reason I feel ashamed,” but they can also hear within that message the conscientiousness that Salkovskis is referring to. The client is encouraged to say this reasonable statement in a non-shamed posture. So head up – firm voice, look the therapist right in the eye and say it. If it doesn’t feel quite right to the client change the wording and add bits on until it hits the exact spot.

Here is my top tip, if the statement starts to sound defiant or aggressive coach some muscle relaxation, then get them to stand up straight and say it again. There is a fine line in the muscle tone between making a non-self-shaming summary and being defiant, but defiance is a safety behaviour so it will prolong shame. Defiance is not needed if shame is already waning. You are aiming to get them to make a simple declaration of their position in a calm but convincing way. Not cowering or cringing, not damning themselves or others. Just a straight-down-the-line statement of fact. Sounds simple, but is amazingly powerful.

This mechanism of change here is one that Professor Marsha Linehan would call ‘opposite action’, a bio-neurological strategy based on the assumption that if you take action incompatible with an emotion the mixed messages back to the brain will reduce the intensity of it. In this case, an upright (but not totally rigid) posture, a direct gaze, a calm declaration made with complete conviction in a strong (but not aggressive) voice-tone are all actions incompatible with shame. It might also be necessary to cool the person’s body temperature, take off a cardigan or jacket, and suggest they have a cold drink. All these factors taken together will inhibit the brain’s shame-induction system in that moment.

For clients who are shameful about some past incidents my advice is to deal with the after-effects first, before doing any exposure treatment. Having some confidence that they can reduce a ‘shame attack’ can help them to withstand recounting the actual incident at some stage in the future. So usually in these cases the client gets shameful when he or she encounters a trigger that sets of the memory. In the example we have already used the client sees people in the supermarket with their children coming up to Christmas and regrets not being with her child, Stick with what she can say to herself in the supermarket, as above, (though she doesn’t have to say it out loud, she can still make the declaration in her thoughts). Only when she can confidently manage this type of trigger is she ready to go back in therapy to the incidents around the time when the child was taken into care.

Shame by association when the client is totally innocent is hard to shift but it is helpful to acknowledge that the discomfort felt in the body does not signify guilt, but rather demonstrates a complete rejection of the act itself. Sometimes the client has been encouraged to feel shame. The statement for this client will be something like, “I feel discomfort when reminded of this event because the action itself was so completely against my own values. This feeling is not a sign of guilt, but comes from my firmly held belief in what is right and wrong.” Head up, confident pose, firm but calm tone of voice, say it with conviction, no flinching. Change the wording until it feels correct to the client.

The client may say, “But I feel shame all the time”, and this is where mindfulness is key. Teach the client that each moment unfolds differently, and if you take care of the moments the hours will take care of themselves. It is wise to keep some shame if the shame is justified, as a warning not to repeat the same behaviour again. Remember that shame is a skill in the repertoire of conscientious people, but in excess is extremely damaging to our self-esteem.

Paul Gilbert will be doing a one-day workshop for us on compassion-focussed therapy in London on Jan 8^th 2016. Please go to our Guest Speaker page to see details.