Chapter 5: FINDINGS

 

This chapter presents the findings in relation with the qualitative data as collected from the participants' accounts of their experience of a client who is reluctant to talk.

In order to remain within the allocated word-count the researcher will only show the first twenty five meaning units as discriminated from S1's original transcript. The rest of S1's table of analysis, along with the full analysis in terms of discrimination of meaning units from the other participants can be found in appendix V.

Section two will then offer the specific description structure of S1's experience. The specific descriptive structure for the remaining participants can be found in appendix VI.

Finally, in the last section the researcher will present the findings as a General Descriptive structure of the experience of working with a client who is reluctant to talk.


All Constituents Present in S1’s Description

Constituents of Description Expressed More Directly in Terms Revelatory to a Client Being Reluctant to Talk

1. S1 provides therapy sessions within an eating disorder unit where patients are sent for treatment and so S1 feels it is a slightly unusual situation in that they don’t have a choice when it comes to therapy, and some of them are quite reluctant to talk.
1. S1 feels that perhaps there is a correlation between those patients who are reluctant to talk and the fact that they haven’t got the choice in coming to therapy.
2. Some of them don’t know how to use the space so the silence in the session are actually quite a common feature and S1 thinks it can be interpreted in lost of different ways really.
2. S1 thinks some of the patients don’t know how to use the therapeutic space which often creates silences whose interpretations can vary.

3. S1 once had this very difficult patient in a sense to be with really because she clearly didn’t want to be; she did want to be in the hospital, she did want treatment and S1 always got that feeling, that impression that nothing she did was going to be right.

3. Even though S1 knew the patient wanted to be in therapy S1 always felt that nothing she did was going to be right.

4. The patient had a real animosity towards her father and it was never really clear why and there was a sense that she was withholding information about her relationship with him. S1 and her team weren’t really sure if there was some abuse, or what. The patient wouldn’t tell them.

4. S1 learns that the patient has a very hateful relationship towards her father, whose details she would purposefully keep secret from S1 and her team.

5. The first time that the patient was silent in the session was about 3 or 4 sessions in and S1 was asking about her relationship with her father. The patient was saying that she hated him. And it wasn’t quite clear why it was, that perhaps she could tell S1 more. And she suddenly became very withdrawn. S1 was left thinking “have I stumbled into something that is very painful… or.. or what really”

5. S1 felt that her attempting to explore something seemingly very painful resulted in the patient withdrawing into a prolonged silence.

6. As the therapy went on S1 got the sense that there was always something that the patient wasn’t telling her and her team. She almost needed to tantalize S1 and her team. It was almost a way of keeping her in their minds really. No matter what they said she wasn’t going to tell them. And it seems over the months, it seemed to sort of figure that it was her way of keeping in people’s mind. It was somehow “I am not going to let you in and therefore you will be wondering why” and that’s how she seemed to kind of keep people engaged.

6. The patient tantalizes S1 and her team by withholding the information they want so as to keep them thinking about her.

 

7. Other time the patient would be silent in the session because she seemed to be very angry because something had happened in the unit. She hadn’t been allowed to go out at the week end for example because she hadn’t put enough weigh so she would treat S1 as if it was all her fault that she couldn’t get to go out and so she wouldn’t really talk to S

7. When the patient’s needs were not met she would be blaming S1 and then sulk.

8. If S1 tried to find out what was going on the patient would say things like “the team hates me, what’s the point of talking? There is nothing that can be done about this. Noting is going to change.”

8. S1’s efforts to reach out to the patient are met with hopelessness and dismissal.

9. In another situation the patient just closed down practically for the whole session and S1 decided not to say anything to her. Later the patient told S1 that she really didn’t know what she was thinking or feeling at all. S1 got the sense that the patient was almost floating in a kind of pre-verbal world; the patient just couldn’t locate herself anywhere.

9. An unperturbed silence allowed S1 to sense that the patient was almost floating in a kind of pre-verbal world where thoughts and feelings were impossible to pin down.

10. S1 tried to get the patient to start labelling some of the things that were coming up for her. The patient got very angry and said “why didn’t you tell me to do that before? We are coming to the end of the admission; you could have told me this before…”

10. S1’s offers to help the patient formulate her thoughts and feelings turned into an opportunity for the patient to put her down and criticize her work.

11. The patient was once able to tell S1 that if she started eating, and started recovering, then there would be nothing, that nobody would understand what her pain was. So therefore there would be nothing to keep her in people’s mind.

11. If the client talked then there would be nothing for other to hold her in their mind.

12. Sometime S1 got this sense that the patient was like a kind of massive rock, stuck there, that whatever one did one couldn’t bulge this rock. The patient wanted to want, wanted to be like other people who want more from life but somehow she couldn’t want anything.

12. S1 feels impotent with her patient for whom it seems impossible to ‘want’.

13. For S1 it was almost as if the patient couldn’t initiate anything in her life and so was leaving the other to take responsibility for keeping her alive. The patient often said that she didn’t want to be alive, but she didn’t want to kill herself either. She didn’t want to take the initiative to kill herself but she actually saw little point in living. So the patient was leaving it to every body else to keep her alive. It was a handing in of one’s life.

13. S1 has the impression that her patient is completely passive and unwilling to take any kind of responsibility in her life.

14. In one particular session S1 realised part of herself was almost retaliating. She thought “ok… if you don’t want to talk, I wont talk either”. S1 had actually come to a complete dead end, and just didn’t know how else to get her to talk. S1 tried all sort of little things: observations, little prompts, but the patient wasn’t going to do or say anything. And so S1 was left at a complete loss.

14. S1 repeatedly sees all her efforts reduced to nothing. Feeling frustrated and at a complete loss S1 respond by also being silent.

15. For S1 it was actually very calm. She felt quite relaxed as she just let her mind wander and just see what came into her mind.

15. The silence is comfortable for S1 and it allows her to be open to what comes to her mind.

16. At the end of this session S1 asked the patient how was it for her. The patient replied that it had not been comfortable at all. S1 realized she was much more comfortable than her patient was in silence. The patient said “it’s not comfortable at all, but I don’t know what to say, and I don’t know what I am thinking or feeling”

16. S1 learns that in silence the patient was anxious, uncomfortable and unable to symbolise her feelings.

17. In the following session the patient did actually start talking quite a lot. S1 thinks the patient found it uncomfortable enough to actually decide to take some initiative in the session but that didn’t last.

17. The previous experience seemed to have invited the patient to react positively, only to return later to her previous mood.

18. The patient was communicating a great deal, but not with words. She was actually very articulate, a well spoken person and educated, so she had the words but somehow not for her emotional experience. She couldn’t really talk about that.

18. Even though the patient was articulated she could not use language in order to explore her feelings.

19. S1 feels as though her and her patient did have a relationship but it was a very difficult one. The patient did want therapy, even though she wanted to attack it. She wanted to attack it but she wanted S1 there so that she could attack her. So S1’s purpose was to be attacked and to survive the attack.

19. S1 felt her only role in this relationship was to be there and survive the repeated attacks from the patient.

20. The patient said to S1 right at the end that one of the reasons she found it so difficult to explore was because she was so afraid, she didn’t have any idea how long the admission was going to last, and it seemed to S1 as though she had a major kind of attachment problem. Because the patient thought it was going to end at any moments, she didn’t feel secure enough to be able to really work with it, to explore and she had to keep constantly sort of establish, sort of keep S1 there in a way.

20. S1 learns the patient did not wish to resolve her feelings as this would have meant becoming attached to S1 and therefore suffering her loss when the treatment ends.

21. S1 thinks that those patients want you to be able to use the space for them in a way and by actually not using the space it feels very withholding. S1 feels as though the therapist is withholding something, or attacking in some way.

21. S1 feels the patient wants her to use the therapeutic space and therefore it would be persecutory to leave the patient fend for herself in it.

22. When S1 is in the room it’s a case of trying to gage what is going on in terms of what’s happened before in the therapy, what you know about that patient really, to sort of gage whether you can let the silence be, or whether you need to intervene.

22. S1 is mindful of the context in which a silence takes place. Its ‘tone’ is an indication if she needs to intervene or not.

23. S1 thinks the anxiety of those patients is so great that they just can’t put it into words. S1 supposes that with most of these patients there is something very early about their experience and it’s almost as though it is a preverbal experience of not being held. And so it creates enormous anxiety, they feel uncontained in that silence so usually S1 feels like she has to start and create a sort of verbal structure for it in a way.

23. S1 thinks she needs to create some sort of verbal structure that can hold and contain an otherwise unboundaried and anxiety-provoking space for the patient.

24. With those particular patientsthey had a real problem with the symbolic language and so it’s really a case of talking about something much more concrete. For those patients who got very stuck in silence S1 has tried to introduce something outside of the room, so perhaps trying to get them to be talking a little bit about home life, or something then start using that in more symbolic ways. With no material there is very little to work with.

24. Those patients who find it difficult to talk about themselves seem hardly able to use language creatively. So S1 invites them to talk about more mundane topics which she then attempt to link symbolically.

25. Sometimes the silence can feel quite persecutory to S1 as well. One particular patient was very contemptuous and angry and seemed to expect that S1 had all the answers. S1 ended up being sort pulled into behaving into quite a clumsy way with her, saying or doing the wrong things and she made it very clear that S1 wasn’t much good to her.

25. S1 is put into the position of the expert and expected to have all the answers, which pushes S1 to show her limitations in clumsy ways. The patient then uses this as an opportunity to put S1 down.



5.2 S1's Specific Descriptive Structure of Working with a Client who is Reluctant to Talk

In order to remain within the word limit only the specific descriptive structure of S1 will be presented in this section.

S1 feels that perhaps there is a correlation between those patients who are reluctant to talk and the fact that they haven’t been given the choice of coming to therapy. For her, some patients don’t seem to know how to use the therapeutic space which often creates silences whose interpretations can vary. One patient did express a wish to be in therapy, but seemed to have needed to use it so as to regularly make S1 feel as if nothing she did would ever going to be right. Once, an attempt at exploring a particularly painful issue saw the patient withdraw abruptly into what until the end of her admission became a mysterious retreat. This episode left everyone in the hospital forever wondering about her and what had happened. It was almost as if the patient could only relate to others by keeping them forever guessing and wondering. If she ever talked, the client once admitted, then there would either be nothing for others to hold her into their minds or she would become attached and later suffer a great loss when her treatment ends.

If her needs and wants could not be met the client would blame S1 and verbally cut herself off from her. S1's repeated attempts to reach out to the patient would invariably be met with hopelessness and dismissal, further attacks and critics of her work. Sometimes and for no particular reasons S1 would just be left in silence and feeling attacked, anxious, powerless, clueless and deskilled. For S1 it was as if in this silent withdrawal the patient was floating in a kind of pre-verbal world where thoughts and feelings would be impossible to grasp. At other times the patient would put S1 in the position of an expert and expect to receive all the answers, which ultimately pushed S1 to show her limitations in clumsy ways and provided the patient with yet another opportunity to put her down.


Eventually S1 would end up feeling very frustrated and at a complete loss. She once decided to share her feelings about the relationship with her client, and things somehow improved slightly, if only for a little while before they got back to before. In retrospect, S1 believes the only role she had in this relationship was to take in and survive the repeated attacks from her patient.

Exasperated, S1 once decided to stay in silence which she actually found comfortable and creative. For the patient however, this experience had made her anxious, uncomfortable and confused. If this difficult experience seemed to have pushed the patient to talk more in the next session, S1 admits that it didn't seem to have changed her at all.

Disempowered, S1 felt there was nothing that she could do to influence her patient for whom somehow it seemed impossible to ‘want’. Even though this patient was articulate she could not seem able to use language creatively in order to explore her feelings; the patient would remain passive and unwilling to take any kind of responsibility for her life. In those circumstances, S1 admits that she feels disappointed with herself that she cannot give anything back to the patients. If S1 learned that she could rely on her thoughts and feelings in her work, she also found out that she could not necessarily make use of interpretations. So at times she invites the patient to talk about more mundane topics which she then attempts to link symbolically. However, it seems that talking about concrete things has no real therapeutic value and simply amounts to filling up an empty space.

S1 is mindful of the context in which a silence takes place. Its ‘tone’ is an indication if she needs to intervene or not. She claims her role is to help patients use the therapeutic space by creating some sort of verbal structure that can hold and contain an otherwise un-boundaried and anxiety-provoking therapeutic experience. For S1 it would be persecutory to leave the patient fend for herself in the therapeutic space.


On the contrary, with another patient, S1 felt comfortable in the silence. She would let her mind free and communicate her passing thoughts to the patient who in turn seemed somehow able to accept her in her world and respond creatively. This patient seemed more able to use language symbolically and let S1 sense and provide the motherly presence and permission to feel which, it seemed, she had never really been given before. In retrospect, S1 thinks their relationship was secure enough to let the patient come closer and use the therapeutic space creatively while sharing feelings and ideas openly.


With those patients who feels lost in particular, S1 finds herself completely at a loss and empty. For some patients the silence reminds her of death. In those moments there aren't even feelings or thoughts, but only a void. With another patient, S1 had this really uncomfortable feeling that she couldn't help but be pulled into rescuing her from some anxiety of separation evoked in the silence. S1 felt as if she was literally glued to her.

Even though sometimes it is really difficult to keep, hope is for S1 a crucial element in her work. She believes that if the patient can see the therapist survive what goes on in their silences then this can be powerfully therapeutic.



5.3 General Descriptive Structure

Four main themes were identified by the researcher in the general descriptive structure:


  1. Positive feelings evoked in the participant
  2. Negative feelings evoked in the participant
  3. Feelings evoked in the therapist for their clients
  4. Participants' learning experience

As advocated by Wertz (1984) the invariant meanings will be illustrated whenever necessary by what the researcher thought were the most representative extracts from all the transcripts produced during the research interviews.




5.3.1 Positive feelings evoked in the participant

The impression that the therapeutic space was being used creatively in the silence was verified by the participants experiencing the following feeling:


- Taking time

The client was felt to be reflecting on what had just been talked about and seemed to be processing some insight. In this silence there is a sense that a form of learning is happening for the client who is considering what has just been brought to light in the session. This moment is almost representative of some change in action and transports a clear and definite impact and therefore time is necessary for the client who turns himself internally in a need for privacy. As S3 noted “I think silence is very useful. I think it’s very valuable. I think sometimes when awareness comes out it needs some stillness to realise what’s just come to our mind, what we are feeling in our body. We have to come to terms with what has just revealed”.

- Secure

The participant somehow feels confident that he can make use of the on-going silence as a therapeutic tool of exploration for the client's experience. This moment is felt as an opportunity to help the client at this point in time specifically; it is used as a space for the client to make his first steps into a new phase of understanding about himself. In a silent union with the client the participant feels they are together while facing the unknown. As S7 puts it “But above all of that I always had a sense that it was the client’s choice not to say anything for a moment”.


- An empowering trans-personal space

This type of silence is felt as a shared experience whose positive energy leaves both client and participant changed positively. The moment is almost felt as if something inexplicable and almost religious is unfolding in the room. As S3 reports “I don't know if it is a spiritual thing or may be some sort of trans-personal thing; but it can be very empowering”.



- An opportunity for the client to 'exist'

The client feels he only needs to 'be' in a reassuring and non-demanding but secure and respectful presence of an Other. In this silence the participant feels he is perceived by the client as being-there but detached, observing but not controlling. As S1 noted: “With this patient the experience was more of needing to be next to a young child. It was an experience of being with a sick child who just wanted a presence, who didn’t necessarily wanted me to give her anything but just a presence, just a sort of containing presence [...] I think she was actually quite pleased to be given permission; to start feeling and thinking about feelings as well.”


5.3.2 Negative feelings evoked in the participant

When the client is reluctant to talk the following negative feelings may be evoked in the therapist:


- Stuck and at a loss

The participant is confronted with a silence whose tone leaves him not knowing how to engage with the client anymore. At this point nothing seems to really work in order to reach the client and the participant has the feeling of having ran out of ideas. This situation may baffle the participant may to the point of him wondering what the client is effectively getting out of therapy.

If not literally empty of words, the client's discourse comes across as peculiarly abstract, controlled or disembodied, without life or meanings - its only purpose being to fill up some space. As S5 puts it:“The feeling of frustration doesn't quite capture it but it think it is more like feeling incredibly stuck”.

- Cut off, rejected and not allowed to create a rapport

The participant feels as if being kept at a distance, if not completely dismissed from the therapeutic relationship altogether as the client is not even offering an opportunity for exploration. The client simply doesn't want to be involved in the relation, or have anything to do with the therapist at that moment. As S1 recalls: “Sometimes the patient would just sit there with an angry expression on her face, very very drawn and I was just left feeling 'what have I done?'”


- Deskilled and made impotent

Either left in silence, bluntly or more subtly, the participant is reminded of his obvious failures to be a competent therapist as the client is antagonizing and sabotaging the participant's efforts. For example S1 would be left thinking to herself “I am a hopeless therapist; I haven’t got a clue what to do with this person” or, as S6 would recall “she would tell that basically you are shit but in the nicest possible way during the course of the session”.


- Controlled and tantalized

The client behaves in such a way that the participant is forced to think about her in between sessions. For the most part this device seemed to be implemented by for example withholding information, or getting in touch with the therapist outside

sessions. As S2 said “The client once sent me an email right before my four week’s holiday saying that it was our last session because I would probably not want to carry on working with her. I replied it was certainly not going to be our last session”.

- Denied as an individual

Here the therapist is left feeling he is being used as an object, a container for sanitary needs, or even as an 'extension' of the client. As S2 would recall: “It feel like the client can’t wait to get out of the room. She seems kind of guilty, almost like she’s kind of chat in the room and quickly got off before I could say 'hang on minute; look at this mess you left in this room'” or as S5 said “I feel there was no space, the client wasn't giving me the space to be in that relationship with her as a person”.

- Assigned the position of the responsible expert

The therapists is cast into the role of an expert and handled the responsibility for the client's therapy or even life. As S6 saw it “the client was constantly expecting me to answer her questions. I recall that every single session for the first two years would end with the client getting up and saying “what should I do? Tell me what to do.” For S1 “it was almost as if the patient couldn’t initiate anything in her life and so was leaving the other to take responsibility for keeping her alive”.

- Attacked and punished

The findings show that most participants felt at some point or another attacked and punished by a client who came across as particularly persecutory in the relationship. As S1 puts it “I feel as though I and my patient did have a relationship but it was a very difficult one. The patient did want therapy, even though she wanted to attack it. She wanted to attack it but she wanted me there so that she could attack me. So my purpose was to be attacked and to survive the attack”.



5.3.3 Feelings evoked in the therapist for their clients

The analysis of the experience under investigation also uncovered feelings in the therapists about their clients. The present findings seem to suggest that in most cases the clients who were reluctant to talk appeared to their therapists as if they were:


- Angry

Most participants felt their clients' attitude was reflecting a huge amount of anger and rage. As S2 would put it “I realise that I have to know how to survive over a long period of time when faced with someone who is very angry”.

- A dead and an empty 'object'

The client is in the room but somehow life seems to have escaped from him. In its place is left a gap, an empty void reminiscing of death itself. As S7 puts it “When the client was quiet he would almost become an object rather than a subject... I could make whatever I wanted of him rather than to ask him to relate”. For S2 “When things are bad I can feel a kind of sleepiness, just like a closing-down. It’s almost like if the energy has been sucked out of the room and I find myself struggling with that emptiness. It is a very odd feeling to be in the room but not be there”.


- Unable to symbolize

The participants feel that their clients seem to find it particularly problematic to use language in an effort to transform feelings into words. As if the client hadn't had the time yet to learn how to inject their words with feelings, there is an impression that something in their clients is somehow very 'early' about their experience. As S1 puts it her client seemed somehow like “floating in a kind of preverbal world where feelings were impossible to grasp and symbolise”.


- Anxious to lose

In this instance the therapist felt that their clients were concerned with being abandoned and left behind. As S1 would recall The patient said to me right at the end that one of the reasons she found it so difficult to explore was because she was so afraid, she didn’t have any idea how long the admission was going to last, and it seemed to me as though she had a major kind of attachment problem”.

The client seems uncannily aware of the situation with them and between them and their therapists, yet any kind of therapeutic change seemed hopeless and unattainable. As S5 puts it When I point things out to her or make a reflection, or an interpretation, it is not that it just doesn't sink in; the client is reluctant to take it in. I have this image of her spitting it out and when I remark this out to her there is a pause where the client gives this impression of examining it, and chucks it away”.


- Finding it enormously difficult to change

The client seems uncannily aware of the situation with them and between them and their therapists, yet any kind of therapeutic change seemed hopeless and unattainable. As S5 puts it When I point things out to her or make a reflection, or an interpretation, it is not that it just doesn't sink in; the client is reluctant to take it in. I have this image of her spitting it out and when I remark this out to her there is a pause where the client gives this impression of examining it, and chucks it away”.


5.3.4 Participants' learning experience

Participants have benefited from the experience and felt themselves to have developed in the following area:

- Reflexivity

Participants found themselves reflecting more on their potential contribution in their clients being reluctant to talk. As S2 would put it “I reflected on myself being so formulaic and realised it was very difficult for me to feel empathy and compassion towards someone who would sit there for 6 months not really reciprocating my efforts”.


- Acceptance

Following on a certain amount of self-reflection about their own attitudes and sometimes negative reactions most participants felt to have subsequently become more accepting of their client's reluctance to talk, and of their individualities as a person. As S2 says “it made me start to connect with his client again and not see her as this really “oh my God what’s happening” but thinking that this is who she is and on this basis try to connect with her more humanly.”


- Use of internal feelings to guide themselves in the unknown

In those instances the participants attuned themselves with added sensitivity to their own feelings in order to 'sense' the silence and decide to let the client 'be' or intervene and explore what it was that was being expressed in the room. As S1 puts it “I am picking up my own feelings, my own counter-transference of what the silence might be about.”

- Remaining true and resist colluding

Silence triggers an anxiety-provoking state of not knowing in which it is easy to 'act out', especially after being relentlessly attacked and persecuted. As S4 showed In the past I tried the ‘scaring each other out’ approach which is that if the client is quiet then I will be quiet in return. I wonder if at the time I wasn’t somehow engaged in some fight, some kind of challenge between me and my client”.

Some participants, especially the less experienced ones, admitted being drawn, willingly or unwillingly, into trying to 'incarnate' what they had learned from school resulting in a contrived and inauthentic approach. As S2 said “I think I need to learn to show more of my vulnerability as I am not that kind of “all knowing person” the client has for fantasy. I need to learn how to live with this kind of unknowing. My vulnerability around that has been a key message”.


- Awareness of a need to survive and keeping faith

The findings suggest that in those intense situations a key element in therapy is the ability to survive the client while holding on to a sense of hope. As S1 admitted rather poignantly at the end of her interview “I suppose I have to carry a lot of hope. For some of those patients they have given up life and sometimes it is very difficult for me not to give up as well. I have to try to keep that hope alive”.


The following chapter will examine those findings in the light of the reviewed literature.

   

 

Contents

Abstract

Introduction

Literature review

Methodology

Research method

Findings

Discussion

References

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