The strategic dialogue

 The dialogic process

An effective clinical dialogue, which is structured around the “objectives” sought by the client, should have the effect of improving the quality of care. The client should have the natural feeling of a journey of “joint discovery”. This is what helps patients gain trust, strengthen feelings of empathy, and begin the process of change from the start of treatment. This helps considerably in building the solution. We must keep in mind that these elements are known as the common factors for good and effective therapy (Hubble et al., 1999). By using "circular questions", "questions with the illusion of an alternative", "cognitive reframing", "paraphrase", "metaphor" and "anecdote", we can create a semi- structured that transforms the therapeutic encounter. Aristotle defined the conditions for effective rhetoric: it involves the use of ethos (essentially the credibility of my argument, do I trust you?), pathos (emotions, or even more for the client, do I care what you say to me? (using logic, for the therapist this can be crucial, because the client may wonder if what you are saying is correct and appropriate for their situation (for my given situation?).

So what we can say so far is that communication style and technique are of primary importance, how we pay attention to it and use it is up to us. It must also be recognized that in the presence of another person, all behavior is a form of communication and has communicative value. When we believe we can be non-directive, we turn a blind eye to human "reality." It must be understood that it is the therapist who asks the questions, but who can rarely be asked questions, the therapist sets the time of the appointment and ends it when he considers it necessary, he changes his body language and the tone of his voice when he agrees or disagrees with the client in front of him, he indicates to the patient where to sit and all this is normally done on his "ground". Our indirect influence on the process of human interaction known as therapy is significant. It may also be important to note that the only other time we experience these types of power relationships is probably in childhood and it is perhaps not surprising that people revert to the type of relationships already experienced in certain conditioned situations.

Effective communication for psychotherapeutic change

What effective dialogue should do is use a subtle form of communication to induce change from the first meeting. An interactive systemic dialogue can be seen as transforming the nature of any initial clinical encounter from one of investigation and diagnosis to one that helps the clinician assess the "true" nature of the problem and intervene in the process. functional of the problem. It becomes an intervention that changes the problem we are working on, but it also helps us define the problem and therefore distinguish the type of perception/problem. For example, simply ask a patient suffering from an anxiety disorder whether they confront or avoid their problems when confronted with them. When elaborated, this simple question can greatly help us discern phobic and obsessive perception and behavior.

This dialogic intervention begins the therapeutic change at the initial phase. Here the work seems subtle, but at the same time it is complex. In therapy, we find patients who arrive with too clear a definition of their problem, too rigid and too sure. And in this case, questions help broaden the lens. In other cases, patients may come with too diffuse an idea of ​​their problem and so the questions help us focus their minds on something concrete and achievable. Once the goal is set, the dialogue moves from general to specific and becomes increasingly narrow with the use of discriminating questions that lead the clinician to discover how the person's individual, unique problem works, in their own unique context (Gibson, 2019a; Nardone, 2007; Portelli et al., 2013).

The phases of the dialogue

Initial stage

This phase must begin with questions that help define the problem or the objective to be achieved. In this case, it is appropriate to use circular questions, but also linear and simple questions, modifying and gradually elaborating them to begin to include questions with the "illusion of an alternative". Questions with the illusion of an alternative become relevant to both the clinician and the patient and become an effective tool for conducting treatment. Questions with the illusion of an alternative are structured so that they contain two opposing possible answers. The customer will have to choose the one that best suits their situation. They can be open and honest or charged and, used effectively, have a positive effect on the outcome. As the dialogue progresses, the question sequence is structured as a sort of "funnel" that begins with general questions and gradually narrows down to the most relevant features of the person's problem (e.g. with anorexia: "Would you prefer to change slowly and in a controlled manner? Or quickly and in an uncontrolled manner?" The question is an illusion because it seems that there is a choice, yet it oscillates between changing in a way or change in another, either way it is oriented towards change.

Secondary phase 

Recapitulating and reframing what the patient has said helps to redefine the problem with them and take stock of the work accomplished so far in the session. Circular cropping and paraphrasing can and usually are used. So, after a sequence of two or three questions to the client, we need to reframe what they said and summarize it in the dialogue: “so far…”. This allows us to confirm whether we have correctly understood their perception of “things”. Acceptance of reframing and paraphrasing is also a subtle form of self-deception and self-conviction. Effective paraphrasing is not limited to verification, it can also allow us to rearrange or repunctuate the sequence of events.

Tertiary phase and prescription phase 

Only once we have engaged the customer, defined the problem and qualified their needs from their perspective can we move to the prescription phase. At this stage, the patient must be ready to engage in the interventions proposed by the therapist. The phase of prescribing a good dialogue becomes inevitable and the prescription or intervention proposed by the therapist stands out as a logical conclusion of what has gone before. The use of metaphors, aphorisms, and anecdotes, to evoke the desired sensation towards certain behaviors, such as disgust, fear, anger, pleasure, etc., must directly target the person's dysfunctional perception which maintains the problem from which the patient wants to free himself. Former British Prime Minister Clement Atlee once said that being a politician is "being part butcher and part surgeon": having removed large chunks of irrelevant data through our dialogue, then surgically carried the work down to the redundant interactional script, we should add the final touch which is the prescription. At this point, the patient should receive the correct "dosage" for their problem. Asking too much of the patient will not change the situation, but conversely, asking too much could well block or prevent change and lead to the failure of the therapy.

Analog communication

According to White (1989), analogical language can be used to externalize the problem, that is, the problem can become a separate entity and therefore external to the person or relationship that was seen as the problem. In other words, “the problem becomes the problem.” The use of analogical and figurative language helps reduce resistance to change, since patients are not asked to do anything and only their behaviors or opinions. The message is conveyed in a disguised way, as it were. Suggestions may be embedded in a story or communicated through metaphors such that the subject is not directly involved, but the evocative power of the story or image counters the patient's conceptions and behaviors . Analogical language can be used to create aversion to an undesirable behavior or to promote a more functional alternative (Gibson et al., 2016).

Propose solutions

The prescription phase should be considered one of the most important stages of therapy because it is both the end and the beginning of therapy. This phase must be kept in mind throughout the dialogue. Begin therapy with the end in mind.  

Change

Change-oriented communication must be woven into the very fabric of every element of dialogue, which includes the verbal, non-verbal and para-verbal aspects of communication. By adopting an effective communication approach, we can be more certain that the client will implement the prescribed interventions and desired change (Gibson, 2013a, 2019b, 2019c; Nardone, 2007; Gibson et al., 2016).

Language and structure

Adapting our mode of communication to the unique perceptions of the customer, unique and non-repeatable, introduces an important aspect that leads to change. If we don't fertilize the soil, the seeds of change may never take root. By focusing on communication and paying attention to the axioms of communication, (Watzlawick, et al., 1967), we can find ways to quickly help the customer. These modes of communication allow you to bypass the four types of resistance we talked about previously. The use of prosody (or pauses for emphasis and concentration), suggestive and strategic repetition of the prescription and the introduction of redundancy (such as the use of a code word), l The introduction of a redundancy (like the sound of injunctions found in post-hypnotic assonances), combined with the moment of prescription, all this increases the probability that the client will follow us to get out of their mental, relational and emotional traps. behavioral. Once released and in the final therapy session, the client should be told what we have done to achieve change and we should remove any sense of mystery from our work. The client must realize that it is he who brought about his change and that we have only succeeded in helping him get out of his own way, thus increasing the sense of autonomy and faith in his own resources.