Building the therapeutic relationship when talking is hard

This section is for questions relating to therapy, assessment, formulation and other aspects of working with people in mental health services.

Building the therapeutic relationship when talking is hard

Postby firegal » Tue Jan 24, 2017 2:53 pm

Just looking for general tips/resources really.

I'm in CAMHS placement at the moment and while I have several clients where I feel like I'm making a really good start at building a solid therapeutic relationship, there are just a couple that are totally stumping me because of their real reluctance to talk in session.
I think I might be putting the cart before the horse a little because where people are a little more talkative it's very easy to spend a few sessions getting to know them, but with some of these less talkative people I find myself feeling very on the spot and then jumping in too quickly with strategies that, I get the feeling, barely register. I'm guessing they feel like they can't talk because they don't know me yet, but I don't know how to get to know them without talking!

In both of the cases I'm thinking of, the young person is in such a low place that it's very difficult to talk about interests or hobbies (my usual go to topics for getting to know you stuff) because they will tell me they don't do anything, there's nothing they enjoy.

I'm wondering about including some more activities stuff rather than such on the spot discussion, but it's not something I've done a lot of and I could really do with some inspiration!
User avatar
Posts: 515
Joined: Mon Jan 14, 2013 4:55 pm

Re: Building the therapeutic relationship when talking is ha

Postby lingua_franca » Tue Jan 24, 2017 4:09 pm

A book I strongly recommend is Direct Work with Vulnerable Children: Playful Activities and Strategies for Communication, which is a treasure trove of creative activities pulled together by a therapeutic social worker. It's full of ideas to help you build rapport with more reticent children (including teenagers), and they're often very simple to implement. Also have a look at the Six-Part Story Method. It's a dramatherapy technique originally but is apparently quite commonly used in CAT. I had training in it when I was working in a centre for refugee youth and I found it really useful. I expect whether you can use it depends on the model you're working with and the expertise of your supervisor, but it's worth looking into.

The following are activities I've used with young people as part of my research into intergenerational trauma/collective memory of mass violence. Some of them were part of a one-off meeting, others were used with children whom I worked with for over a year. Much of this work took place in refugee camps. I'm not a therapist and this wasn't therapy, so some of them might not be appropriate for your setting, but you could adapt them.

1.) Mental map. Get paper, felt-tips, and crayons and ask the young people to draw a 'mental map' of their community - not a physical representation of where they live, but all the places that are important to them, for whatever reason. You can ask questions as they draw. Some kids take off with this on their own, others will require more direction, e.g. "What's a place where you've felt...?", "Where do you hang out the most?" Some kids will feel more at ease if you draw something alongside them.

2.) Creative family tree. Get a big box of colourful beads and buttons, and ask the young person to choose a button for each person in their life (including themselves) and to arrange them on a piece of paper. Prompt them to talk about why they're choosing that button for that person, and encourage them to think about why they're placing the buttons where they are. This can be a very good way to elicit stories about the family.

3.) Ask young people to bring something to the session that they feel represents them. It could be song lyrics, a photo, anything. I've been brought all sorts of things and it's usually a springboard into discussion. In your setting you could also maybe ask them to bring something that represents them as they'd like to be, to get an idea of any changes they hope to make.

4.) If you feel creative yourself, get some masks and paint them to display a range of emotions - a basic approximation is enough - and when the young person arrives for session, invite them to pick a mask for themselves and one for you. You can talk about why they chose those particular masks today. It can be a way to get a quick sense of their mood and their attitude towards you as they walk through the door. Sometimes it's better for the two of you to make masks together. It can also be used to prompt discussion about the different kinds of masks and roles we all adopt in different situations.

5.) Room 101 - get a box and tell them that this is a place where they can put everything that's on their mind that's bothering them or that they would like to get rid of. You will need some props again: things to represent different feelings, different situations and events. They don't necessarily have to be literal representations of those things. In fact if young people really aren't engaging my experience is that they like to work more 'obliquely' - i.e. they will pick up a bright red ball and say it's their anger, but they will avoid using the photo of the angry person.

6.) Make a postbox for your room and explain that if they find it easier than speaking, young people can write notes to you during the week and 'post' them when they arrive for the session. You will read them and they will help you to know what you should think about for the next session. Emphasise that they don't have to do it, but the option Is there. I used this because some of the kids in my groups didn't like speaking up in front of others.

Finally, in my experience some reluctant young people respond much better if you dive confidently into an activity, if you set a firm plan for the session ("We are going to do this, then we're going to talk about..."), or even if you ask some more challenging questions straight off the bat. During my research I had some painfully awkward meetings with older teens who didn't want to talk at all, and I made the mistake of trying to talk about innocuous things like their hobbies to help them feel at ease with me. They didn't feel at ease. They just felt bored and like I didn't get them. Of course, this firm directive approach might be the wrong idea for the young people you're working with, but it's worth bearing in mind that some teenagers will trust you much more readily if you come across as someone who is steering the ship rather than someone who is waiting for them to set the course.

One last thing (OK, so that one wasn't final), when working in CAMHS inpatient I fell in love with what Dan Hughes calls 'empathic guessing', which I was introduced to through Miriam's book. There was one girl who struggled to identify her emotions and to understand that her choices have consequences, and she especially struggled to express them to people she didn't like (and I was in this category - she had significant attachment difficulties and she divided everyone into angels and demons within a day of admission). At first I made the mistake of asking very open-ended questions whenever I was on her 1:1 support, thinking that it would be best not to push her and she would talk to me when she felt ready. This would be right for some children but it was unhelpful for her, because she didn't know herself where to begin and she just felt unsupported by me. The pivotal moment came when she was due to move to another placement, self-harm had escalated, and her response to, "How of you feel about leaving?" was a stony, "I'm not bothered." I thought about the empathic guessing, and said, "Well, it seems to me like you're very used to being in hospital. You've been in so many all over the country and it's a lot of moving around for someone your age. I'm wondering if it starts to feel like you don't have a home after a while." I will never forget that nod. Obviously I've anonymised this anecdote, but you get the gist. She allowed me to sit with her for nearly two hours that night and suddenly, out of seemingly nowhere, we had a rapport. I did a lot of wondering out loud, and she would shake her head if my conclusions were wrong and nod if they were correct. In the past I would have been very reluctant to try something like this in case I ended up putting words into a teenager's mouth or made them feel like I was pushing them to say certain things, but for kids who have had really horrible histories, the knowledge that someone has noticed what they might be feeling (and is prepared to acknowledge when they've got it wrong!) is important.

I hope some of that helps.
"Suppose a tree fell down, Pooh, when we were underneath it?"
"Suppose it didn't," said Pooh, after careful thought.
Piglet was comforted by this.
- A.A. Milne.
Posts: 725
Joined: Tue Sep 14, 2010 11:29 pm

Re: Building the therapeutic relationship when talking is ha

Postby firegal » Tue Jan 24, 2017 4:46 pm

Lingua thank you so much for such a lengthy well explained post! So many great and helpful ideas that I will most certainly be drawing upon, in fact your mental map and family tree activity is confirming my own thought (had shortly after posting) of doing something very similar that we practiced as an activity in systemic teaching and I think it might well click for this person.

For anyone else stumbling upon this thread I also found this in googling with lots of creative activities inspired by play therapy ... ntions.pdf

Keep the suggestions coming folks :)
User avatar
Posts: 515
Joined: Mon Jan 14, 2013 4:55 pm

Re: Building the therapeutic relationship when talking is ha

Postby BlueCat » Wed Jan 25, 2017 4:57 pm

My first thought there is that when kids are feeling really low and hopeless, it must seem really incongruent asking them to talk about things they enjoy. All the above ideas sound great, but if talking is important, why not focus on getting to know them now as they are? What does their day look like, what do they do, what do they think about, what's really truly the hardest thing etc? It'll be a heavy session, and you'll probably come out of it feeling low because you will be empathising with them, but joining them where they are at will be so very validating of their experience in a way that trying to get to know the lighter side of their life just wont. Just my thoughts, from a co-regulation type perspective.
There's no such thing as bad weather, just the wrong clothes. Billy Connolly.
User avatar
Site Admin
Posts: 2784
Joined: Mon Mar 26, 2007 2:42 pm

Return to Clinical Issues

Who is online

Users browsing this forum: No registered users and 3 guests