Conversational Errors and Common Ground Activities in Psychotherapy—Insights from Conversation Analysis

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  Many patients leave psychotherapy although in need. What can professional practitioners and researchers assume what happened? Trying to receive a response from these patients we too often are left without an answer. In this paper I introduce to
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  International Journal of Psychological Studies; Vol. 8, No. 3; 2016 ISSN 1918-7211 E-ISSN 1918-722X Published by Canadian Center of Science and Education 134 Conversational Errors and Common Ground Activities in Psychotherapy—Insights from Conversation Analysis Michael B. Buchholz 1 1 International Psychoanalytic University (IPU), Berlin, Germany Correspondence: Michael B. Buchholz, International Psychoanalytic University, Stromstr. 3, Berlin, 10555, Germany. E-mail: michael.buchholz@ipu-berlin.de Received: May 30, 2016 Accepted: June 29, 2016 Online Published: August 2, 2016 doi:10.5539/ijps.v8n3p134 URL: http://dx.doi.org/10.5539/ijps.v8n3p134 Abstract Many patients leave psychotherapy although in need. What can professional practitioners and researchers assume what happened? Trying to receive a response from these patients we too often are left without an answer. In this paper I introduce to psychotherapy discourse some concepts taken from linguistics and Conversation Analysis (CA). The reason is that what psychotherapists of every kind do is “talk-in-interaction”. During such talk Typical Problematic Situations (TPS) appear which are well known in a macro-analytic perspective (if a  patient comes late to the session, does not talk or blackmails the therapist with suicide threat). However, there are many TPS that can be detected by a micro-analytic perspective only. CA is a tool helping to idenfity this type of TPS. One relevant CA-concept is Common Ground, a psychological and linguistic concept which requires special activity from both participants in an interaction. Conversational “errors” that risk to tear the Common Ground often go unnoticed. Presenting segments of transcribed therapy sessions I want to direct attention to the details of how ‘errors’ in Common Ground activity happen, how they are noticed and dealt with by skillfull therapists or how they can become repaired. Among others I use transcription details of two suicidal patients. The transcripts are from the CEMPP-Project (Conversation analysis of Empathy in psychotherapy process), conducted at IPU, Berlin. Thanks to a grant by Köhler-Stiftung, Germany. Keywords:  psychotherapy, conversation analysis, typical problematic situations, Common Ground 1. Introduction 1.1 Person or Method—What Is the Problem?   The everyday saying, “it’s not what you say but the way you say it” is too rarely scientifically observed in  process research and clinical practice. Therapists are trained to think in terms of “intervention” technology reducing “disorders” and producing “outcome”. However, prominent researchers warned: “As a rule, the study of psychotherapies has been favored over the study of  psychotherapists—as if therapists, when properly trained, are more or less interchangeable ... We think that one reason for this relative paucity of research on psychotherapists is an implicit  bias in thinking about therapy leading to the assumption that it is basically a set of methods, techniques, or procedures that are efficacious, in and of themselves, in curing or ameliorating  psychological and psychiatric disorders... This bias views the personal element or the subjective equation in human experience and relations as a source of error in research to be minimized or controlled...” (Orlinsky & Ronnestad, 2005, p. 5) The field studied (Hill, 2006) the therapist’s personality (Aveline, 2005), influence of training (Baker & Neimeyer, 2003), motives for professional choice (Barthel, 2011; Buckman & Barker, 2010), therapists’ response to patients’  personality (Colli, Tanzilli, Dimaggio, & Lingiardi, 2013; Dinger, Strack, Leichsenring, & Schauenburg, 2007), countertransference (Hayes, 2004; Kächele, Erhardt, Seybert, & Buchholz, 2013), dreams (Hill et al., 2014), negative side effects (Kächele & Schachter, 2014), general process responsibility (Krause & Lutz, 2009; Lindgren, Folkesson, & Almqvist, 2010) or attachment style (McCluskey, 2005). All these studies, of which I mentioned only a few came to the same conclusion: “The therapist matters” (Luborsky, McLellan, Diguer, Woody, & Seligman, 1997). Therapist or method—this question was tested in a  ijps.ccsenet.org International Journal of Psychological Studies Vol. 8, No. 3; 2016 135 conflicting scientific debate (Elkin, Falconnier, Martinovich, & Mahoney, 2006; Kim, Wampold, & Bolt, 2006; Wampold & Bolt, 2006). However, is the method or the therapist the only choice? 1.2 Situationism—An Alternative Solution There is another alternative: situationism that guides the work of conversation analysts, following certain methodological rules (Note 1) which can be summarized in guidelines:  First  , don’t look primarily for external variables as e.g., social background, attachment style, motivation or type of  personality. These abstractions produce  generic  explanations; however, in therapy we look for how  these variables (and many others) are individually  realized (or not) in situated interaction. Second  , make talk-in-interaction the center of analysis. This generates data close to the situational dynamics. These dynamics are steered by gaze, body movements and talk. Talk includes words, the embodied voice, rhythm used to achieve a definition of the situation. Third  , look for how a Common Ground (Enfield, 2006; Stalnaker, 2002) is established or not. Common Ground outlines the horizon we talk to, it is never a “given” but to be established in situations.  Fourth , talk-in-interaction has the double potential to repair (Dingemanse et al., 2015) an imbalanced Common Ground and to tear the Common Ground to pieces.  Fifth , direct your attention to how Common Ground activities are managed successfully or not. Without a Common Ground situationally maintained by interactional and talking activities every special technical procedure in psychotherapy heavily risks to fail. A situationist approach furthers microanalytic observation of small scale events that have the power to deteriorate otherwise “good” relationships or vice versa, to steer flat relationships to deeper emotional experience. Negative events are called here “conversational error” because they are situated in conversation as the main and universal tool of all psychotherapy. What therapists do is “talk-in-interaction”. In all psychotherapeutic endeavors there is a consistent amount of “drop-outs” close to 10%. Clients leave therapy although they need it. This may be due to false diagnosis or inappropriate institution (Werbart, Anderson, & Sandell, 2014). However, it might be useful to study the details of conversational “errors” that go unnoticed—that “errors” happen is not the problem. What is more important is whether they are noticed and repaired between familiy members (Corrin, 2010), especially mothers and their babies (Emde, 1981) or in psychotherapeutic interaction (Barnett, 1980; Castonguay & Hill, 2012). The problem is not the “error” but the lack of repair. Here I want to point to a level of conversation which linguists have termed “Common Ground”. If “errors” on this level go unnoticed they have an effect to interrupt further progress. What follows is an explication of Common Ground. 2. Method   2.1 “Common Ground” and Conversation Analysis (CA) It is necessary to describe what Common Ground means. There are two offsprings. First, there is a psychological use: “She accomplishes this by choosing her wording based on their Common Ground so far, and by collaborating with her partner to reach the mutual belief that he has understood her  ” (Wilkes-Gibbs & Clark, 1992, p. 183).   This is from a paper about “coordinating beliefs in conversation”. How do people manage to make sure that they understand their words reasonably well? The answer is that we create a Common Ground by directing attention to a common perceptual object in our common environment. We point to it saying something like: “Nice book shelf you have there”. I can see it and I can see that you see it and when You respond: “Yes, I have bought it directly from the factory” two important things happen: By “Yes” the  perceptual object is transformed into a conversational   one and then you link   to the conversational   object another experience or, even better, a series of experiences. So there are three transformational levels: perceptual-conversational-link. Later, when having studied some transcript material, I will add a fourth one. Transforming the perceptual into a conversational object is an act of conversation. It informs both speakers that they have  joint attention (Bangerter, 2004; Tomasello, 2003) and for at least one moment they have created a Common Ground. This opens a horizon to project further activities. Thus, although “Common Ground” sounds like a piece of territory it is meant as an activity. Common ground can disintegrate if this activity fails or is ended.  ijps.ccsenet.org International Journal of Psychological Studies Vol. 8, No. 3; 2016 136 These activities are psychologically risky. If speaker A would utter his sentence and B would completely ignore it, neither respond with words nor a gaze, then sensitive persons can sometimes doubt if they have made the utterance? If an unpopular group member enters and his greetings are not responded by team members and they leave the room the recipient is punished by non-resonance. His attempts to build up a Common Ground are refused. Who ever made this painful experience knows how threatening it is and how much one’s personal integrity depends on basic resonance. Second, there are linguistic definitions. Linguist Nick Enfield gives a definition very close to the psychological one: “The pursuit and exploitation of mutual knowledge, shared expectations, and other types of common ground ... not only serves the mututal management of referential information, but has important consequences in the realm of social, interpersonal affiliation. The informational and social-affiliational functions of common ground are closely interlinked” (Enfield, 2006, p. 399). If the conversational level is achieved a lot of further social psychological accomplishments become possible: to exploit mutual knowledge, shared expectations and interpersonal affiliation. Participants produce and reproduce Common Ground-why? Psychologists would point to  generic factors like interpersonal attraction, sympathy, etc. From a linguistic point of view comes a further reason: “Common ground is a resource that speakers exploit in inviting and deriving pragmatic inference, as a way to cut costs of speech production by leaving much to be inferred by the listener” (Enfield, 2006, p. 401). Conversation is very slow as compared to thinking. Conversation is linear, thinking is circular and has a multi-processing architecture. There is a speed difference between conversation and cognition. So, to share your thoughts completely with someone would become an aim forever unattainable. But if you share a Common Ground reliably you must not say everything because you can trust that the listener will infer correctly (Schmitz, 2014). This kind of trust is a conversational strategy to reduce complexity (Luhmann, 1979). Producing and reproducing a Common Ground, from a linguistic point of view, is indispensable for every talk-in-interaction  because of the speed difference between conversation and cognition and, I think, this is a good argument to be added to the psychological ones. If one has both aspects in mind one can more easily see how sensitive, how risky and how complicated Common Ground activities are. Applied to therapeutic conversation one must conclude that every single intervention has a good chance to fail if the Common Ground is not established or is in risk of decay. I know of no psychotherapy  process research study paying attention to this level. Common Ground is related to and different from other psychological concepts. Attachment quality, e.g., is acquired in early life and built into a person’s patterns as “working model” (Stalker & Davies, 1998); attachment, although directed to others (“objects”) is an individualistic conception while Common Ground is a conversational concept including, as I tried to show, processes like affiliation, joint attention, etc. In  psychotherapy process Common Ground is related to the concept of “alliance” (Safran & Muran, 2000) between therapist and client. However, to come to a working alliance agreement is relatively late (not in the first session) and presupposes a lot of Common Ground activities. This is why conversation analysts pay much attention to how a conversation starts. 2.2 Conversation Analysis (CA)  Conversation Analysis (CA) has contributed to situationism by scrutinizing the details of talk-in-interaction (Sidnell & Stivers, 2013). CA is a respected method in psychotherapy process research (Buchholz & Kächele, 2013; Peräkylä, 2013; Peräkylä, Antaki, Vehviläinen, & Leudar, 2008). Starting with the analysis of turn-taking operations, CA has turned its focus on repair-activities, details of questioning, formulations of therapeutic utterances, analysis of beginning and ending sessions, affiliation and disaffiliation (Muntigl & Horvath, 2014a, 2014b) and a lot of other topics studied in microanalytic detail. Meanwhile, CA expands its scope to study prosody of voices (Weiste & Peräkylä, 2014) and how therapists contribute to realize therapeutic tools (Buchholz & Kächele, 2015; Weiste, Voutilainen, & Peräkylä, 2015) aiming to better understand how empathy is interactionally realized (Buchholz, 2014; Wynn R. & Wynn M., 2006). One observation seems to hold: there is a kind of hologram-principle, once formulated by William Blake, that there is a world in every grain of sand (in Bruder, 2003) (Note 2). However, this principle unfortunately is a non-symmetrical one: one single “false remark” sometimes has the power to destroy an otherwise well working  ijps.ccsenet.org International Journal of Psychological Studies Vol. 8, No. 3; 2016 137 therapeutic relationship; thus, lots of “good remarks” not necessarily indicate that a break of Common Ground could be ignored. Everything seems to depend upon the therapists’ sensitivities to realize that a “Typical Problematic Situation” (TPS) is being build up. Can the therapist quickly reorganize one’s mode of operation, attitude, thinking about the patient’s disorder and utterance—or not? A general principle can be recommended: therapists should be trained to think freely about at least two types of response before delivering an utterance. Holding to such a principle gives the therapist even when “under fire” (Note 3) a grounded feeling-having a choice intensifies your sense to be an autonomous person making decisions which increases your self-worth. Self-reports of expert clinicians have described macro-analytically difficult situations ranging from patients coming late to a session, not talking or blackmailing the therapist with suicide threats. Here I want to go through some TPS threatening to tear up the Common Ground that can be described only microanalytically. However, once analyzed they function as “eye opener”. One can see and hear them. To gather a pool of TPS can in the future result in higher perspectives of typicality what makes TPS. I will present segments of transcripts (all translated from German). I will start with examples where the TPS was skillfully handled. 3. Results   3.1 Agenda Transforming Utterances The 28 th  session of a psychoanalytic treatment with an obsessive-impulsive female patient treated by a female analyst starts as follows: Trancription Rules (simplified): [ ] begin and end of overlapping utterance = contiguous utterance (.) micro pause (1.2) length of pause in seconds : elongation . fall in pitch , slight rise in pitch ? Rising in pitch (not necessarily a question) WORD Loud speech Word accentuation talk surrounds quiet talk hhh exhalation .hhh inhalation > < surrounds talk spoken faster < > surrounds talk spoken slowly Wo(h)rd laugh particle ( ) approximation of what is heared  ijps.ccsenet.org International Journal of Psychological Studies Vol. 8, No. 3; 2016 138 The patient’s first remarks—can they be heard as a narrative? A narrative (Jefferson, 1978) has a kind of standard format: beginning with a “pre-announcement” (“Wanna know what happened so terrific to me yesterday?”) directing the listener’s attention, a narrative is followed by “setting the stage”, bringing the story slowly to a “climax” of tension, where the listener is supposed to utter his “stance” (Stevanovic & Peräkylä, 2015) which is followed by a decrease of tension. The story is often closed by a coda of evaluation (“moral of the story”) exhibiting the conclusions the teller draws from his experience. This tension curve of narration cannot be found here. The patient uses not a narrative, but a reporting   mode. She adds one event after the next using “and then”-connections. No build-up of narrative tension can be found and, what is most important, she begins her report with an evaluative phrase that she got through the day somehow. The slightly negative self-evaluation of her day (line 5)  precedes  the report while in a narrative it is placed at the end of the telling. Contrasting to the positive emotional content of the reported experiences is the negative evaluation at the start. We see this mode of reporting in the prosodic analysis conducted with PRAAT (Boersma & Weenink, 2013) which shows a non-emotional mode of talk. I only represent here the German version of the patient’s phrase (line 11-12) “after the weather wasn’t so good then um” (for a full analysis see Buchholz & Reich, 2015). The overall report is in the same manner.
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