Note: This article was originally published in Substack on 20 Dec. 2024

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In my other Substack Full Circles, I talked about our yearnings for deeper conversations in our relationships.

In case you missed it, here’s the related previous post:

Words matter. They are the medium to connection, ideas, and emergent realities.

As the legendary social work professor turned TED Talk superstar Brene Brown says, “Language is Praxis.”1

Praxis refers to the process of putting what you know into practice.

We are taught a lot about the theories of human development, psychopathology, and theories of psychotherapy, but we rarely get into the details that is exchanged in the four very private walls of therapy: conversations.

“The word “conversation” is made up of con, “with” and versare, “turn”. Conversation is taking turns.

Musicians describe a good improvisational performance as a good conversation.

If we resist the urge to over complicate things with our elaborate theories, we must learn to be the midwife of good conversations.

More, it takes practice to develop the skills required to handle difficult conversations in therapy. (See our related study on DCT).

Yes, some clients are harder to engage than others, but the burden of responsibility should not fall on the shoulders of the client; it’s on us. We are not the experts of their lives, but we should be skilled enough to guide them.

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The aim of the following framework is to allow you to appreciate which level of conversation is taking place between you and your client.

Now lets take a look at each of the five levels of conversation.

1. Informational

We need enough information about the client in order to understand their presenting problems and the context in which they are experiencing them.

But, don’t go digging around for “true but useless” (TBU) information.

Our urge is to gather all the necessary facts about the person.

We have to ask ourselves: At that given stage, have we earned the license to pry?

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Related to TBU:

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“If information is all we need, everyone would have become billionaires, with perfect 6-pack abs,” says writer and entrepreneur Derek Sivers.

In other words,

Information ≠ transformation.

Nevertheless, at the Informational level in therapy, clients want us to know what they want us to know. We gather, we listen, we suspend judgment, and we take notes.

To facilitate conversations at an Informational level:

1. Gather enough information to be on the same page:
   – “Please tell me about you, what you like doing, what you do for fun.”
   – “In light of the issues you raised, I love to know what usually occupies your mind.”
   – “What would you like me to know about you that we haven’t had a chance to talk about?” “Is there anything I haven’t asked you that you actually would appreciate if I did?”
   
2. Provide relevant information:
   As we gather information, our clients too might have stuff they want to know more about. “What’s wrong with me?” “Is this normal?” “Am I going insane?” “Is there a book that you would recommend to help me in this area?”
   
3. What to Expect:
   Clients may not necessarily know exactly what to expect in therapy, what the therapist’s role is, and their role too. This is an invitation for clients to be an active agent of change. Therapy is not done unto them, but with them.

2. Emotional

At this second level of conversation, clients enter beyond the realm of the logical, and begin to share what’s going on at a “felt” level.

As mentioned in my other post,

At the Informational level, head speaks to head.

At the Emotional level, heart speaks to heart.

The therapist’s task at this level is to listen carefully, and provide dynamic empathy that facilitates a deepening of what they are saying, while also implying that “You can go further, and I am with you.”

The world of affect often requires a guide to go deep. Feelings can be present just beneath the surface of our conscious mind. We can create a climate to welcome them into the therapy room.

This sort of guidance to go further requires “climate control,” not “command and control.”

Do we create an invitational climate in the room, in the conversation, for the client to go deeper?

Carl Rogers famously said,

In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way:
How can I provide a relationship which this person may use for his own personal growth?2

Even the use of the voice—our primary instrument in the conversational music—can be used to facilitate going deeper into the emotional realm.

A simple statement like “How are you?” can be asked in so many affective ways.

“How are you?” (Upbeat greeting)

“How are you?” (A matter of fact)

“How are you?” (A softer, slower intonation).3

All of the above suggests that we have a facilitative role to play, especially in helping a client to go deeper.

As one of my intellectual heroes, anthropologist Gregory Bateson said,

“It takes two to know one.”

To facilitate conversations at an Emotional level:

1. Focus on going inward:
   – “As you were hearding to the arguments between your parents, what’s going on for you on the inside?”
   – “What is an inner struggle that you are facing?”
   
   
2. Focus in the moment:
   – To a client who seemed to be reporting traumatic events matter of factly. “Can we take a moment here… as you are talking about all of the hurts, how are you feeling right now in your body?”
   – To an anxious client at the start of the first visit: “What is it like to finally be here at your first appointment?”
   
   
3. Differentiating primary and secondary emotions:
   – “I see that you are very angry (secondary emotion) for what your friend did to you (target of the emotion), though you didn’t show it to him. Underneath it all, what feelings are stirring beneath angry, if any?” (assessing primary emotion, potential hurt, dissappointment, sadness)

We must not be afraid to go there.

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SEE RELATED:

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3. Confessional

Therapy is not exactly a confessional booth at the church, but we could do well to open up the door for people to speak what has been buried in their hearts for a long time.

I’m not exactly sure how to account of this, but in the first ten years of my clinical practice, with some exceptions, I don’t frequently hear people speak at a confessional level. In the last decade, I seem to hear more and more people speak the unspokens.

And the effect of such a conversation is unshaming, unhiding, and is welcoming; this seems to have a profound impact.

If the Emotional level is deep in the sea, Confessional Level disclosures are like uncovering stuff buried under the ocean floor.

As mentioned in the Full Circles essay, shame is an innocent emotion. It is afraid of being judged, unloved, and made small.

It seems to me that those with clinical levels of symptoms are more likely to present with old ghosts that haunts them, often in the form of painful, traumatic and intrusive memories, or guilt-ridden deeds. A core pain exists deep within.

Thus, to not only give voice to these psych-aches, but to be received by another in a caring manner, can be transformative.

But, especially at this Confessional stage, we must not think that we need fix or solve anything. It just needs to be wholeheartedly received.

I’ve listened to hundreds of hours of therapy recordings, and one of the common mistakes that practitioners make is that we prematurely move to the Activational stage (i.e., behavioural activation, SMART goals), when the client is still raw from opening up to you. I’ve unfortunately made this mistake too.

It is worth re-iterating the following points:

At the Informational level, we say what we “Will Say.”

At the Emotional level, we say what we “Won’t Say.”

At the Confessional level, we say what we “Can’t Say.”

When your clients start to speak to you what they typically “can’t say,” learn to be still. Be a with-ness. Be with the person. Let them speak of their demons. No need to be afraid. Co-regulate with them, moment by moment.

Soon, we can learn to dance with our demons.

To facilitate conversations at a Confessional level:

1. Invitational:
   – “Is there anything I haven’t asked you that you actually would appreciate if I did?”
   – “What are some things that have been left unspoken in your life?”
   – “Is there somethings that are hard to speak about—and you also have every right to not go there if you don’t want to.”
   
   
2. Receiving the person:– “As I hear you speak about these painful memories, it must have been hard to even give voice to them… I see that you are not trying to blame others, but you were left on your own device to fend for yourself…” (intent: empathic resonance and speaking some of the further unspokens).
   – “I really appreciate you sharing this… I’ve deep respects for you for doing so, because you are taking courage to address this, as well as countering the urge to hide from all of this.” (intent: explicating respect).- “I’m deeply moved by what you are telling me. I can see that you are working hard to make sure this doesn’t get passed inter-generationally, for the sake of your children.” (intent: emotional disclosure, and affirmation of client’s intention).
   
   
3. Processing:
   – “What is it like for you to speak about “X” with me? How are you feeling right now?” (intent: regulating in-the-momentaffect)- “Is this feeling foreign to you? Do you feel too raw or vulernable at this point?”– “Do you have any unexpected fears that come to surface after talking about this?”(Note: Sometimes clients might have some nagging feelings of confidentiality, even though this was previously discussed. Assurance might be helpful here. In addition, some clients might begin to project and experience a feeling of being judged by you. This needs to be addressed so that they are experience you as you, within the interpersonal dimension that you have with your client).

4. Experiential

At the fourth level, through the improvisational nature and emergent reality of the therapeutic conversation, a new experience is found.

The client feels a qualitatively different experience of the self. The client may feel inspired by the dialogue that just occurred.

Such experiences can happen spontaneously. More often than not, it is the therapist responsibility to facilitate an Experiential level of conversation when it is called for.

After more than 12 sessions with Sophie, my client’s outcomes seemed to plateau.4 We had covered a lot of grounds on helping her with her fear of traveling away from her hometown. She now has the tools and strategies to deal with the anxiety. However, I had a suspicion she was still avoiding the inner experience of complex emotions, which bubbles into anxiety. Taking an affect phobia (i.e., fearing to experience feelings within) perspective, I spoke of my concerns for her. While she was not exactly avoiding to drive out of her comfort zone (she did on a few occasions), I worried that she was dissociating from the inner feelings. In other words, though she was doing “exposure therapy” on the outside, she was still evading the feelings on the inside.

The proper “exposure” for her might be affect exposure.

“Oh boy,” Sophie responded.

We laughed.

I brought up a symbol that most of us had seen before on ambulances or in hospitals. The Rod of Asclepius is a single serpent entwined around a staff.5

It’s a symbol of healing. The very thing that is poisonous from the serpent, now is a source of healing—if she volitional chooses to approach what she fears on the inside (and not just do the exposure work on the outside).

With Sophie’s will on-board (as well as knowing that she is physically fit), I begin to set this up. I was scratching my head on what might be the best way to induce the emotional experience. The simplest came to mind: Hyperventilation.

Immediately, just based on this suggestion, I could see a change of expression on her face. “Really? Are we doing this?” she said with some nervous laughter. “Only if you are on-board with this. No one can force you to…”

“Okay…”

“Don’t worry. I will do it with you. And we can stop at any given point in time.”

“Ok… it’s now or never…”

With my stop-watch at hand, we did a 60-sec burst of shallow and fast breathing.

If anyone walked passed my office at that point in time, others might have thought the client and therapist have gone hysterical.

“Oh my goodness… oh my goodness…”

“Ok… I know your heart rate is up… the point is not just that… the point is that this triggers all sorts of internal fears of not being in control. Don’t ‘fill’ it up; ‘feel’ it.”

I suggested for Sophie to augment with some cognitive approach. “Imagine you are riding an elephant. The elephant is a massive beast of energy, but the rider can still guide the direction it is heading.

I met Sophie three weeks later. She said she slept like a baby that night, and seemed to make a turn around the corner in relations to her fear of traveling outside her comfort zone. She’s now enjoying the drive.

To be clear, I’m giving this not as an example of “here’s how to do therapy.” I’m trying to highlight the following point: We are most persuaded by our own experiences than explanations. When the time is ripe, we can facilitate that.

To facilitate conversations at an Experiential level:

1. Evoke in-the-moment emotions:
   – Instead of talking about the client’s relationship with their parent, have them picture that particular parent on an empty chair and speak to them.- Instead of gathering information about who is special in their life, get the client to picture them in their mind’s eye, vivify that image of that person right here, right now.
   
   
2. Experience, don’t tell:
   – Instead of trying to get parents to empathise with their child, get the parent to speak as if they are that child (i.e., in first person). Follow-up by getting perspective, if that have an inaccurate view of what the child is experiencing.
   – Use photos of loved ones to evoke memories; this can help form a more coherent narrative in one’s history, or in grief work.
   
   
3. Beyond words:
   – Sometimes, some experiences are beyond words. Don’t be too quick to get clients to name it. Let them know that they can sit with the inner experiences as they unfold, while you are right there with them.
   

Note: Theses suggestions doesn’t do justice to the vast and wide array of possibilities at an Experiential level. Readers can look up further on areas such as somatic therapy, emotion-focused therapy, hypnosis, play therapy, etc.

5. Activational

Since this article is addressed to psychotherapists, I’d say this regarding the fifth stage, Activational level.

A client who is not ready or keen to take action based on what you suggested does not mean that they are not ready for change.

A client would be activated if it’s something that they care about, something that they feel they can do, and is meaningful to them.

A client did not do your thought diary homework is not because “resistant to change.” Perhaps because they don’t see any meaning in that exercise, or it’s either too easy/too difficult.

In other instances, we might have been premature in trying to get our clients into an Activational level. The client might have stuff they have not yet told you, as they are getting to know you and feel if they can entrust you with some of the “not-yet-spoken-about” stuff.

What we need to keep in mind is this: Is what we are hoping for them to do leading them into their learning zone, or panic zone (or pointless zone)?

If we are not mindful of their limits, overstretching their LZs can tip our clients into panic zones (PZs). You know you are in PZ when they are overwhelmed or flooded with strong emotions. If you are not cognisant of the impact of their history, being emotionally unregulated in the PZ can at times lead to re-traumatisation.

Panic zone materials are usually either too far a stretch in terms of the content to be learned, or the topic at hand might have triggered ghosts of the past that have not been addressed.

The learning zone is the sweet spot between the comfort zone and the panic zone. Not too little, not too much.

To facilitate conversations at an Experiential level:

1. One Thing:
   Near the end of a session, ask you client, “What is one thing that stands out from today’s conversation?” A task can be suggested based on the client’s response.
   If a client says that he was surprised how much he had missed painting (that is if you enquired about what he cares about in the Information level), you might suggest for him to park aside one evening before the next session to put aside his phone, refrain from Netflix, and set up his painting equipment.
   Therapy homework can be potent, which stretches beyond the therapy hour, but only if it’s imbued with meaning for the client.
   
   
2. Know the Direction:
   At any given point in time in your work with a client, be clear on these three things:
   i. Where are we?
   ii. Where are we going?
   iii. Why?
   This not only provides a sense of structure, but also a sense of directionality. When North is clear, clients are more mobilised and willing to walk the hard mile.
   
   
3. Experiments with Truths:
   Sometimes, a client might not be at a stage to take action, simply because aren’t clear on “where to go” just yet. In such instances, the goal is to figure out the goal.
   Instead of going on an “exploit” mode” (focusing on using existing knowledge and direction to maximise benefits), take an “explore” mode (focusing on discovering new options and possibilities).
   Be unwedded to results at this stage. The aim is to try things out.
   For example, a client might not have a clue on what career to pursue. Provide a framework to your client to aid their exploration. I might draw up this venn diagram, True, Useful and Beautiful.6 And I would ask clients to initially see where they find a nature gravity towards in various parts of the three circles, and then explore jobs in that realm.
   

Misalignment

Now that we have covered all of the five levels of conversation, it is worth stressing that when we are speaking at different levels, there is likely to be a disconnection.

A client who is wanting to take action (Activational level), but because of your psychodynamic neo-Freudian orientation, you think it would make sense to dig deeper into the past (Informational and Emotional levels), you might experience alliance rupture.

A client who is wanting to talk about stuff that is difficult to bring up (Confessional level), but because you are anxious about where this is going, your attempt to get clients talking about SMART goals (plus the evidence says so), you might inadvertently make the client feel invalidated.

Misalignments are risk factors for premature dropouts.

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Remember: It’s not what happens, it’s what we do with what happens.

Every therapeutic conversation moves to different levels as emergent possibilities arises. Every chance of realignment and repair is a chance to not only be on the same page, but also to truly be with each other in a deep way.

Our clients yearn for a deeper connection.

It is on us to create the appropriate climate for that to happen , so as to touch, move and inspire them.

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