“As I already said…”

WIN_20151217_180233Therapists 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.

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8 thoughts on ““As I already said…”

  1. I think my therapist has the opposite problem! It was my first time in therapy and hard to open up. I sometimes wish I could be a fly on the wall and listen in on other people’s sessions to hear how things are supposed to go… It’s still new for me.

    Liked by 1 person

    1. Thank you so much for your comment. This is exactly why the first and most important thing for the therapist to do is honour what is being said, and the second strategy is to help make sure nothing is missed. Your communication is precious. It does also depend what type of therapy you are having. If you are in DBT then the therapist first has to concentrate on anything you are doing that could leave you dead before the next session, as dead clients do NOT do well in therapy! If you are on fire the therapist needs to put out the flames, not ask you how you feel about being on fire. But after that is done then there is more space to hear how the fire got started, and hopefully ensure that the flames don’t start up again.

      Liked by 2 people

  2. Although in the past we’ve talked about the existance of suicidal thoughts I’m having I have a hard bringing it up unless I am asked straight up. So we haven’t talked about it. Thanks for the insight.

    Like

    1. Ah, OK. Let me be validating, it is a very hard topic for you to breach, and you have every right to hope your therapist will read the signals and ask. But if he or she doesn’t do that, and you feel so bad you might end up losing your life, then it can’t make you feel any worse to say it. Take a deep breath and say, “Can I just stop you there for a moment, I have something to say, I have been contemplating suicide”. That’s it. That’s all you have to say, your therapist should take it from there. If you can’t say it in person, then text or call ahead of time and leave a message. Or hand over a note. It doesn’t matter how the message gets through – only that it does. I am sending good vibes.

      Liked by 1 person

  3. Thank you so much. immensely helpful article.
    Dear Christine, wishing you a very Happy Christmas & New Year,
    Love & Brst wishes, Paddy

    Like

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